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Study ObjectivesPoor sleep in adolescents can increase the risk of obesity, possibly due to changes in dietary patterns. Prior neuroimaging evidence, mostly in adults, suggests that lacking sleep results in increased response to food cues in reward-processing brain regions. Needed is a clarification of the mechanisms by which food reward processing is altered by the kind of chronic sleep restriction (SR) typically experienced by adolescents. This study aimed to elucidate the impact of sleep duration on response to visual food stimuli in healthy adolescents using functional neuroimaging, hypothesizing increased reward processing response after SR compared to a well-rested condition.MethodsThirty-nine healthy adolescents, 14–17 years old, completed a 3-week protocol: (1) sleep phase stabilization; (2) SR (~6.5 h nightly); and (3) healthy sleep (HS) duration (~9 h nightly). Participants underwent functional MRI while performing a visual food paradigm. Contrasts of food versus nonfood responses were compared within-subject between conditions of SR and HS.ResultsUnder SR, there was a greater response to food stimuli compared to HS in a voxel cluster including the left ventral tegmental area and substantia nigra. No change in food appeal rating due to the sleep manipulation was detected.ConclusionsOutcomes of this study suggest that SR, as commonly experienced by healthy adolescents, results in the elevated dopaminergic drive of the reward network that may augment motivation to seek food in the context of individual food appeal and inhibitory profiles. Countermeasures that reduce food salience could include promoting consistent HS habits.

Introduction Short sleep duration has been linked to obesity risk in adolescence. However, most research has focused on potential changes in appetite/intake, rather than physical activity or sedentary behaviors. It remains unknown if, in the daily lives of adolescents, sleep restriction increases moderate- to-vigorous physical activity (e.g., by providing more time for it) or discourages such activity (in favor of sedentary behaviors). This was the first study to use gold-standard objective measures to assess cause-and-effect relationships between sleep duration and the resulting activity levels of adolescents in the naturalistic environment. Methods N=104 healthy teens (ages 14–18) completed the 3-week within-subjects crossover sleep manipulation experiment during the summer. Following a 7-night a sleep stabilization week, teens were randomly assigned to 5 nights in Short Sleep (6.5hrs sleep opportunity) or Healthy Sleep (9.5hrs sleep opportunity). Following a 2-night “washout” period, they crossed over to the alternate sleep condition. Throughout the study, they wore validated waist-worn accelerometers to objectively measure sedentary and physical activity levels, and wrist-worn actigraphs to confirm adherence to their sleep condition. Results When in Short Sleep (vs. Healthy Sleep), teens on average slept 112 minutes less (p Conclusion Among healthy adolescents, a realistic dose of sleep restriction did not affect moderate-to-vigorous physical activity levels, but did sharply increase time in sedentary behavior. Given the negative weight and health consequences of sedentary behavior, these results have practical implications for obesity prevention/intervention efforts. They suggest that extending teen sleep may neither encourage nor discourage healthy physical activity, but may help curb unhealthy behaviors (e.g., sedentary behavior). Support R01 HL120879

Introduction Short sleep increases the risk for obesity in adolescents. One potential mechanism relates to when eating occurs, rather than what or how much is eaten. This study investigated the impact of shortened sleep on meal timing and late evening eating in adolescents. Methods 93 healthy 14- to17-year-olds (62% female) completed a within-subject counterbalanced experimental sleep manipulation, engaging in shortened sleep (SS; 6.5 hours/night in bed) or healthy sleep (HS; 9.5 hours/night in bed), each for five nights, with order randomized. Sleep timing was verified through wrist-worn actigraphy. During each sleep period, adolescents completed 2-3 dietary recalls. Repeated-measure T-tests assessed the sleep manipulation effect on averaged times of the first and last eating episode, number of eating episodes after 8:00pm, and range of the daily eating period. Results Youth averaged 2.2 hours/night longer sleep during HS than SS (p Conclusion Shortened sleep resulted in adolescents eating later and lengthening the daily period of time in which they ate, despite typically stopping eating well before sleep onset during healthy sleep. Late evening eating and long daily eating periods have been strongly associated with weight gain, which may help explain the link between shortened sleep and increased obesity risk in adolescents. Support (if any) R01HL120879

Introduction Children with overweight/obesity are more likely to have shortened sleep, though little is known about the role of weight status in insomnia severity, sleep quality, and sleep hygiene in clinically referred youth. Methods A total of 1133 children (43.7% female) presented to a Pediatric Behavioral Sleep Medicine Clinic for insomnia. At the initial evaluation, caregivers of children ages 2–10.9 years (N = 744) completed the Pediatric Insomnia Severity Scale (PISI) and the Children’s Sleep Habits Questionnaire (CSHQ); adolescents ages 11–18 years (N = 389) completed the PISI, the Adolescent Sleep Hygiene Scale (ASHS), and the Adolescent Sleep Wake Scale (ASWS). The PISI was completed during at least one Pediatric Behavioral Sleep Medicine visit subsequent to evaluation and initiation of treatment. Patient height and weight, objectively measured within 3 months of the initial evaluation, was used to determine sex-adjusted body mass index z-scores (BMIz). Hierarchal linear regression models were used to determine the impact of BMIz on baseline PISI insomnia severity scores, and CSHQ, ASHS, and ASWS total scores, after covarying for income. Repeated-measures general linear modeling was used to determine whether weight status moderated improvement in insomnia severity over time, covarying for income. Results For children (ages 2–10.9), weight was not associated with baseline insomnia severity (p=.62) or predictive of insomnia improvement following behavioral sleep medicine intervention (p=.71), though higher weight predicted poorer parent-reported sleep quality (p=.006). For adolescents (ages 11–18), higher weight was predictive of higher baseline insomnia severity (p=.026), though did not predict insomnia improvement over time (p = .86); higher weight was also predictive of poorer sleep hygiene (p Conclusion Initial insomnia severity and subjective sleep quality may be worse for youth of higher weight, particularly for adolescents; these findings increase our understanding of how and when overweight/obesity negatively impacts sleep. Fortunately, youth with higher weight respond equally well to pediatric behavioral sleep medicine interventions as their lower-weight peers, suggesting that these interventions need not be modified based on patient weight. Support (if any) Cincinnati Children’s Hospital Medical Center Division of Behavioral Medicine and Clinical Psychology’s Research Funds

Introduction Adolescents who sleep less may consume more calories during the day; however, shortened sleep may have greater impact on the dietary quality of foods, particularly foods high in sugar content. This study examined the impact of shortened sleep on total caloric intake, macronutrients of food (fats, proteins, carbohydrates), added sugars consumed, and glycemic load/index of foods consumed. Methods 110 adolescents (ages 14–17, M = 15.73(1.80); 63.6% female) underwent a within-subject counterbalanced experimental sleep manipulation, spending either 6.5 or 9.5 hours/night in bed for five nights. During each sleep period, adolescents completed three dietary recalls (reporting amounts and types of foods consumed over a 24-hour period) administered by dietary core study staff. We conducted a series of repeated-measure general linear models comparing averaged weekly dietary outcomes of interest by sleep condition. We also explored whether experimental order of the sleep conditions, family income, or adolescent gender, body mass index (BMI), or race moderated the main effects of sleep condition on dietary outcomes. Alpha was set at .05 for primary analyses and .01 for exploratory analyses. Results We observed a main effect of sleep on carbohydrates (p=.038) and added sugars (p=.009) consumed, as well as the glycemic index (p=.013) and glycemic load (p=.009) of foods consumed. We did not observe a main effect of sleep on total calories or total grams of fat or protein consumed. Exploratory analysis found no significant interactions of the moderators with sleep condition on dietary outcomes. Conclusion Adolescents are consuming more carbohydrates, added sugars, and foods higher in glycemic index and load when sleep restricted, compared to well-rested, despite eating comparable amounts of calories. Sleep restricted adolescents may be drawn to foods that provide quick releases of energy to counteract sleepiness experienced during the day. Support R01 HL120879

Introduction Sleep is vital for healthy development from infancy through adolescence. Despite its importance, false beliefs that conflict with scientific evidence (myths) may be common among caregivers and impair sleep health during these crucial stages. Methods Researchers compiled a list of potential myth statements using internet searches of popular press and scientific literature. We utilized a Delphi process with experts (n=12) from the fields of pediatric, sleep, and circadian research and clinical practice. Selection and refinement of myths by sleep experts proceeded in three phases, including: focus groups (Phase 1); email-based feedback to edit, add, or remove myths (Phase 2); and closed-ended questionnaires (Phase 3) where experts rated myths on two dimensions: (1) falseness and (2) public health significance using 5-point Likert scale: 1 (“not at all”) to 5 (“extremely false/important”). Results Thirty-two sleep myths were identified across three developmental categories: infant (14 myths), child (6 myths), and adolescent (12 myths). Mean expert ratings illuminated the most pressing myths in each developmental category: infant sleep (“Sleep training causes psychological harm, including reduced parent-child attachment:” falseness =4.7, s.d.=0.7; public health significance=4.0, s.d.=1.1); child sleep (“Heavy, loud snoring for my child means he’s sleeping deeply:” falseness=4.8, s.d.=0.6; public health significance=4.7, s.d.=0.7), and teenager sleep (“Falling asleep in class means your teenager is lazy and not motivated:” falseness=4.8, s.d.=0.5; public health significance=4.3, s.d.=0.8). Conclusion The current study identified commonly-held myths about infant, child, and adolescent sleep that are not supported by (or worse, counter to) scientific evidence. If unchecked, these myths may hinder sleep at a critical developmental stage. Future research may include public health education to correct myths and promote healthy sleep among infants, children, and teenagers. Support 5T32HL007901

Introduction Previous studies indicate that lack of sleep might increase risk for unhealthy eating and obesity. This is particularly important during adolescence, when most youth sleep less than the recommended 8-10 hours/night and dietary habits are developed that extend into adulthood. This study investigated the relationship between multi-night sleep restriction and the appeal of food, including neuroimaging to examine the impact on brain responses to food-related stimuli. Methods Healthy 14-17 year-old adolescents (n=39) completed an experimental sleep manipulation across consecutive five-night periods to compare nightly sleep of approximately 9 hours (healthy sleep duration) vs. about 6.3 hours (mild sleep restriction). At the end of each week, participants underwent functional MRI while performing a visual food appeal task. The task included 42 photos in each of four food categories (sweets, snacks, fast-food, meat/fruit/vegetable) and one non-food category. Photos were presented every 3 seconds in blocks of 7 within each category; 6 interleaved blocks per category. Teens rated the appeal of each block of photos. General linear modeling explained regional brain response according to categorical presentation time-courses. Results The pattern of brain responses to the different food types was similar across the two sleep conditions. However, the sleep manipulation led to significant regional effects when contrasting the totality of food vs non-food images. Specifically, when compared to non-food, food images overall resulted in greater activation in the ventral tegmental area (VTA) and substantia nigra (SN) during sleep restriction. Both regions have been previously shown to be involved in processing reward-related information. Conclusion Our findings suggest neuronal responses in reward circuitry for teens viewing food images are influenced by sleep duration. Sleep restriction may affect reward processing of food in teens by increasing brain activation in VTA/SN network components that underlie dopamine-mediated motivational drive. Support Supported by NIH R01HL120879

STUDY OBJECTIVES: Depressive symptoms following adenotonsillectomy (AT) relative to controls were examined in children with obstructive sleep apnea syndrome (OSAS). METHODS: The Childhood Adenotonsillectomy Trial (CHAT) multisite study examined the impact of AT in 453 children aged 5 to 9.9 years with polysomnographic evidence of OSAS without prolonged desaturation, randomized to early adenotonsillectomy (eAT) or watchful waiting with supportive care (WWSC). One hundred seventy-six children (eAT n = 83; WWSC n = 93) with complete evaluations for depressive symptomatology between baseline and after a 7-month intervention period were included in this secondary analysis. RESULTS: Exact binomial test assessed proportion of depressive symptomatology relative to norms, while effects of AT and OSAS resolution were assessed through linear quantile mixed-models. Treatment group assignment did not significantly impact depression symptoms, although self-reported depression symptoms improved over time (p < 0.001). Resolution of OSAS symptoms demonstrated a small interaction effect in an unexpected direction, with more improvement in parent ratings of anxious/depressed symptoms for children without resolution (p = 0.030). Black children reported more severe depressive symptoms (p = 0.026) and parents of overweight/obese children reported more withdrawn/depressed symptoms (p = 0.004). Desaturation nadir during sleep was associated with self-report depressed (r = −0.17, p = 0.028), parent-reported anxious/depressed (r = −0.15, p = 0.049), and withdrawn/depressed (r = −0.24, p = 0.002) symptoms. CONCLUSIONS: Increased risk for depressed and withdrawn/depressed symptoms was detected among children with OSAS, and different demographic variables contributed to risk in self-reported and parent-reported depression symptoms. Arterial oxygen desaturation nadir during sleep was strongly associated with depressed symptoms. However, despite improvements in child-reported depressed symptoms over time, changes were unrelated to either treatment group or OSAS resolution status. TRIALS REGISTRATION: Childhood Adenotonsillectomy Study for Children with OSAS (CHAT), https://clinicaltrials.gov/show/NCT00560859, NCT00560859.

Study Objectives Published experimental sleep manipulation protocols for adolescents have been limited to the summer, limiting causal conclusions about how short sleep affects them on school nights, when they are most likely to restrict their sleep. This study assesses the feasibility and emotional impact of a school-night sleep manipulation protocol to test the effects of lengthening sleep in habitually short-sleeping adolescents. Methods High school students aged 14-18 years who habitually slept 5-7 hours on school nights participated in a 5-week experimental sleep manipulation protocol. Participants completed a baseline week followed in randomized counterbalanced order by two experimental conditions lasting 2 weeks each: prescribed habitual sleep (HAB; sleep time set to match baseline) and sleep extension (EXT; 1.5-hour increase in time in bed from HAB). All sleep was obtained at home, monitored with actigraphy. Data on adherence, protocol acceptability, mood and behavior were collected at the end of each condition. Results Seventy-six adolescents enrolled in the study, with 54 retained through all 5 weeks. Compared to HAB, during EXT, participants averaged an additional 72.6 minutes/night of sleep (p < .001) and had reduced symptoms of sleepiness, anger, vigor, fatigue, and confusion (p < .05). The large majority of parents (98%) and adolescents (100%) said they would "maybe" or "definitely" recommend the study to another family. Conclusions An experimental, school-night sleep manipulation protocol can be feasibly implemented which directly tests the potential protective effects of lengthening sleep. Many short-sleeping adolescents would benefit emotionally from sleeping longer, supporting public health efforts to promote adolescent sleep on school nights.

Objectives The childhood obstructive sleep apnea syndrome (OSAS) is associated with behavioral abnormalities. Studies on the effects of OSAS treatment on behavior are conflicting, with few studies using a randomized design. Further, studies may be confounded by the inclusion of behavioral outcome measures directly related to sleep. The objective of this study was to determine the effect of adenotonsillectomy on behavior in children with OSAS. We hypothesized that surgery would improve behavioral ratings, even when sleep symptom items were excluded from the analysis. Methods This was a secondary analysis of Child Behavior Checklist (CBCL) data, with and without exclusion of sleep-specific items, from the Childhood Adenotonsillectomy Trial (CHAT). CBCL was completed by caregivers of 380 children (7.0+1.4 [range 5-9] years) with OSAS randomized to early adenotonsillectomy (eAT) versus 7 months of watchful waiting with supportive care (WWSC). Results There was a high prevalence of behavioral problems at baseline; 16.6% of children had a Total Problems score in the clinically abnormal range. At follow-up, there were significant improvements in Total Problems (p < .001), Internalizing Behaviors (p = .04), Somatic Complaints (p = .01), and Thought Problems (p = .01) in eAT vs. WWSC participants. When specific sleep-related question items were removed from the analysis, eAT showed an overall improvement in Total (p = .02) and Other (p = .01) problems. Black children had less improvement in behavior following eAT than white children, but this difference attenuated when sleep-related items were excluded. Conclusions This large, randomized trial showed that adenotonsillectomy for OSAS improved parent-rated behavioral problems, even when sleep-specific behavioral issues were excluded from the analysis.

Study objectives Investigate whether a realistic "dose" of shortened sleep, relative to a well-rested state, causes a decline in adolescents' learning and an increase in inattentive and sleepy behaviors in a simulated classroom setting. Methods Eighty-seven healthy 14.0- to 16.9-year olds underwent a 3-week sleep manipulation protocol, including two 5-night sleep manipulation conditions presented in a randomly counterbalanced within-subjects cross-over design. Wake time was held constant. Bedtimes were set to induce Short Sleep (SS; 6.5 hours in bed) versus Healthy Sleep (HS; 10 hours in bed). During the morning at the end of each condition, participants underwent a simulated classroom procedure in which they viewed lecture-based educational videotapes and completed relevant quizzes. Their behaviors in the simulated classroom were later coded by condition-blind raters for evidence of inattention and sleepiness. Results Adolescents had a longer average sleep period during HS (9.1 hours) than SS (6.5 hours). Compared to scores during HS, adolescents scored significantly lower on the quiz, showed more behaviors suggestive of inattention and sleepiness in the simulated classroom, and were reported by adolescents themselves and by their parents to be more inattentive and sleepy during SS. However, the impact of the manipulation on quiz scores was not mediated by changes in attention or sleepiness. Conclusions Although effect sizes were modest, these findings suggest that previously-reported correlations between sleep duration and academic performance reflect true cause-effect relationships. Findings add to the growing evidence that the chronically shortened sleep experienced by many adolescents on school nights adversely impacts their functioning and health.

During the first year of life, infants spend most of their time in the sleeping state. Assessment of sleep during infancy presents an opportunity to study the impact of sleep on the maturation of the central nervous system (CNS), overall functioning, and future cognitive, psychomotor, and temperament development. To assess what is currently known regarding sleep during infancy and its effects on cognitive, psychomotor, and temperament development, we assessed the relevant literature published over the last several decades. To provide a foundation for a more in-depth understanding of this literature, we preface this with an overview of brain maturation, sleep development, and various assessment tools of both sleep and development during this unique period. At present, we do not have sufficient data to conclude that a causal relationship exists between infant sleep and cognitive, psychomotor, and temperament development. Caution should be used in predicting outcomes, as the timing and subjectivity of evaluations may obviate accurate assessment. Collectively, studies assess a wide array of sleep measures, and findings from one developmental period cannot be generalized readily to other developmental periods. Future studies should follow patients longitudinally. Additionally, refinements of existing assessment tools would be useful. In view of the relatively high reported pediatric prevalence of cognitive and behavioral deficits that carry significant long-term costs to individuals and society, early screening of sleep-related issues may be a useful tool to guide targeted prevention and early intervention.

Study Objectives: The research literature on the neuropsychological effects of obstructive sleep apnea (OSA) has yielded seemingly contradictory findings, and narrative reviews of this literature are prone to interpretive errors. We used sophisticated meta-analytic models to minimize such errors, with the goal of clarifying the effect of OSA on neuropsychological functioning. Design: Meta-analytic review of research through 2001. Participants: We reviewed studies of neuropsychological functioning among adults with untreated OSA. Twenty-five studies met review criteria, representing 1092 patients with OSA and 899 healthy controls. Measurements and Results: Two sets of effect sizes were generated. One compared OSA group means against those of healthy controls in case-controlled studies. The other compared all OSA group means against published normative data. Within each data set, 10 neuropsychological outcome domains were coded. In both data sets, untreated OSA was found to have a negligible impact on intellectual and verbal functioning but a substantial impact upon vigilance and executive functioning. Data were mixed with regard to visual and motor functioning; posthoc inspection of the data suggested that tests of fine-motor coordination or drawing were more sensitive to OSA than were tests of fine-motor speed or visual perception. Data were also mixed with regard to memory functioning, probably related to methodologic differences across studies. Conclusions: Etiologic models should emphasize mechanisms known to affect vigilance, executive functioning, and motor coordination but not intelligence, verbal functioning, or visual perception. Clinicians should be alert to OSA symptoms in patients with declines in vigilance, executive functioning, or coordination.

SLEEP DISORDERED BREATHING (SDB) IN YOUNG CHILDREN HAS BEEN ASSOCIATED WITH POOR ACADEMIC PERFORMANCE AND BEHAVIORAL abnormalities, especially inattention, hyperactivity, and other “externalizing” behaviors (e.g., oppositionality, conduct problems).1 Cognitive test findings have been less consistent, but young children with SDB have generally shown diminished scores on tests of intelligence (IQ), attention, and executive functioning.1 Adults with SDB also display inattention, but they rarely show IQ deficits, hyperactivity, or externalizing behaviors.2,3 SDB in middle to late childhood has received much less research attention. Of the 60 published papers reviewed in 2006 by Beebe,1 most enrolled only children aged ≤ 11 years. This emphasis on younger populations has remained true in more recent publications.4 Studies that have examined a broader age range have enrolled primarily young children due to their recruitment strategies (e.g., recruiting from otolaryngology clinics) or have relied solely upon parent report of both clinical symptoms of SDB and behavioral disturbances, which can artificially inflate correlations.1 To our knowledge, only one published study has independently measured SDB and cognitive, behavioral, or scholastic functioning exclusively during middle to late childhood. Rhodes and colleagues5 reported cognitive deficits in 5 children with OSA with a mean age of 13 years. Despite the fact that SDB has been associated with cognitive, behavioral, and functional deficits in studies of thousands of young children and adults, clinicians working with older children and adolescents have extremely limited data to inform evidence-based care. To some degree, findings from younger children and adults might be extrapolated to middle or late childhood. However, the nature of the cognitive and behavioral dysfunction that has been associated with SDB appears to differ in young children versus adults, and it is not clear when or how this developmental shift occurs.2 The risk factors for SDB also differ with age and may confound or moderate the impact of SDB. Further, the adaptive challenges faced by older children and adolescents differ substantially from those faced by young children and adults,6 so the functional impact of sleep pathology in this understudied population may be unique. Finally, older children and adolescents tend to show greater sleep restriction on school nights than do their younger counterparts, and data suggest that, even among children with suspected SDB, typical sleep duration is a reliable correlate of behavioral pathology.7 SDB is unlikely to be benign during middle to late childhood, when problem-solving, social judgment, emotion regulation, and abstract reasoning rapidly mature in a manner that parallels maturation of their underlying neural substrates.6,8 By altering neurochemistry and activation patterns, SDB may disrupt these neurodevelopmental processes.9,10 Moreover, the cognitive and behavioral effects of SDB during middle to late childhood might substantially impact a key adaptive outcome—school performance—at the very time when that outcome is of greatest importance. In the US, middle school grades often determine class placement in high school, and high school performance predicts later outcomes, including school drop-out, failure to enroll in or complete college, adult mental illness, and adult vocational status.11–13 Even if the effect of SDB is modest, its public health impact could be substantial due to its relatively high population base rate. By middle childhood, obesity is a key risk factor for SDB, with 13% to 39% of overweight 10- to 16-year-old children displaying SDB.14 In recent decades, the rate of overweight in this age range has tripled to around 16 percent.15 Thus, despite the likelihood that SDB during middle to late childhood has a significant impact upon cognitive and behavioral functioning and school performance, there is a paucity of relevant data. Moreover, the mechanism by which SDB might result in poor school performance remains unclear. It is generally assumed that the cognitive and behavioral deficits that have been associated with SDB (e.g., inattention) result in poor school performance, but this assumption has rarely been tested. The general approach to most studies in this area has been to consider cognition, behavior, and school performance on the same level, rather than testing a presumed causal sequence. However, they are conceptually distinct, with school performance representing the cumulative result of a number of contributors, such as socioeconomic circumstances and aspects of each student's cognitive skills (e.g., IQ, memory) and behavioral functioning (e.g., classroom behaviors, study habits). The current study had two broad goals. The primary goal was to fill a key gap in the research literature by determining the associations of SDB with cognitive and behavioral functioning and with school performance in a relatively large sample of 10- to 16-year-old overweight children and adolescents. Overweight subjects were studied exclusively to ensure adequate representation of SDB in otherwise typically developing individuals in this age range (e.g., those without genetic syndromes or craniofacial pathology). Groups of subjects showing differing levels of SDB were compared on behavioral functioning and scholastic performance, as reported by multiple sources, and cognitive functioning, as measured via neuropsychological tests. Our hypothesis was that groups with greater SDB would display poorer behavioral functioning, cognitive functioning, and school grades in a manner that could not be explained by methodological artifacts such as reporter biases or demographic confounds. The secondary goal of the study was to clarify whether associations between SDB and school grades are statistically mediated by deficits in cognitive or behavioral functioning, a finding that would support a causal sequence in which SDB leads to cognitive or behavioral deficits that result in poor school performance.

Study objectives To comprehensively review research on the association between childhood sleep-disordered breathing (SDB) and neurobehavioral functioning. Design Qualitative and quantitative literature review. Setting N/A. Patients or participants N/A. Interventions N/A. Measurements and results The findings of 61 studies of the relationship between childhood SDB and neurobehavioral functioning were critically evaluated and synthesized. There is strong evidence that childhood SDB is associated with deficits in behavior and emotion regulation, scholastic performance, sustained attention, selective attention, and alertness. There is also evidence that SDB has minimal association with a child's typical mood, expressive language skills, visual perception, and working memory. Findings have been insufficient to draw conclusions about intelligence, memory, and some aspects of executive functioning. Mechanisms by which SDB might result in neurobehavioral morbidity are being explored, but clinical symptoms such as chronic snoring remain the best predictors of morbidity. Short-term SDB treatment outcome studies are encouraging, but the long-term outcomes are not known. Failing to treat SDB appears to leave children at risk for long-term neurobehavioral deficits. Conclusions Childhood SDB is associated with neurobehavioral morbidity. Applying commonly used guidelines for causal inference, even in the absence of a much-needed randomized clinical trial, there is strong evidence of association, consistent findings, and specificity of effect. There is suggestive evidence that this association fits the expected temporal pattern and that SDB is a biologically plausible cause of neurobehavioral deficits. Clinicians should be alert to the coexistence of SDB symptoms and concerns about a child's academic progress, attention, arousal, or behavior or emotion regulation.