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Consensus Statement of the American Academy of Sleep Medicine on the Recommended Amount of Sleep for Healthy Children: Methodology and Discussion

2016; American Academy of Sleep Medicine; Volume: 12; Issue: 11 Linguagem: Inglês

10.5664/jcsm.6288

1550-9397

Shalini Paruthi, Lee J. Brooks, Carolyn D’Ambrosio, Wendy A. Hall, Suresh Kotagal, Robin M. Lloyd, Beth A. Malow, Kiran Maski, Cynthia Nichols, Stuart F. Quan, Carol L. Rosen, Matthew M. Troester, Merrill S. Wise,

Sleep and Wakefulness Research

Free AccessSleep RestrictionConsensus Statement of the American Academy of Sleep Medicine on the Recommended Amount of Sleep for Healthy Children: Methodology and Discussion Shalini Paruthi, MD, Moderator, Lee J. Brooks, MD, Carolyn D'Ambrosio, MD, Wendy A. Hall, PhD, RN, Suresh Kotagal, MD, Robin M. Lloyd, MD, Beth A. Malow, MD, MS, Kiran Maski, MD, Cynthia Nichols, PhD, Stuart F. Quan, MD, Carol L. Rosen, MD, Matthew M. Troester, DO, Merrill S. Wise, MD Shalini Paruthi, MD, Moderator Address correspondence to: Shalini Paruthi, MD, St. Luke's Hospital, 232 S. Woods Mill Road, St. Louis, MO 63017 E-mail Address: [email protected] Saint Louis University, St. Louis, MO , Lee J. Brooks, MD Children's Hospital of Philadelphia, Philadelphia, PA Liaison for the American Academy of Pediatrics , Carolyn D'Ambrosio, MD Brigham & Women's Hospital, Boston, MA , Wendy A. Hall, PhD, RN University of British Columbia School of Nursing, Vancouver, BC , Suresh Kotagal, MD Mayo Clinic, Rochester, MN , Robin M. Lloyd, MD Mayo Clinic, Rochester, MN , Beth A. Malow, MD, MS Vanderbilt University Medical Center, Nashville, TN , Kiran Maski, MD Boston Children's Hospital, Boston, MA , Cynthia Nichols, PhD Munson Sleep Disorders Center, Traverse City, MI , Stuart F. Quan, MD Harvard Medical School, Boston, MA , Carol L. Rosen, MD Rainbow Babies & Children's Hospital, Cleveland, OH , Matthew M. Troester, DO Barrow Neurologic Institute at Phoenix Children's Hospital, Phoenix, AZ , Merrill S. Wise, MD Methodist Healthcare Sleep Disorders Center, Memphis, TN Published Online:November 15, 2016https://doi.org/10.5664/jcsm.6288Cited by:315SectionsAbstractPDFSupplemental Material ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTMembers of the American Academy of Sleep Medicine developed consensus recommendations for the amount of sleep needed to promote optimal health in children and adolescents using a modified RAND Appropriateness Method. After review of 864 published articles, the following sleep durations are recommended: Infants 4 months to 12 months should sleep 12 to 16 hours per 24 hours (including naps) on a regular basis to promote optimal health. Children 1 to 2 years of age should sleep 11 to 14 hours per 24 hours (including naps) on a regular basis to promote optimal health. Children 3 to 5 years of age should sleep 10 to 13 hours per 24 hours (including naps) on a regular basis to promote optimal health. Children 6 to 12 years of age should sleep 9 to 12 hours per 24 hours on a regular basis to promote optimal health. Teenagers 13 to 18 years of age should sleep 8 to 10 hours per 24 hours on a regular basis to promote optimal health. Sleeping the number of recommended hours on a regular basis is associated with better health outcomes including: improved attention, behavior, learning, memory, emotional regulation, quality of life, and mental and physical health. Regularly sleeping fewer than the number of recommended hours is associated with attention, behavior, and learning problems. Insufficient sleep also increases the risk of accidents, injuries, hypertension, obesity, diabetes, and depression. Insufficient sleep in teenagers is associated with increased risk of self-harm, suicidal thoughts, and suicide attempts.Commentary:A commentary on this article apears in this issue on page 1439.Citation:Paruthi S, Brooks LJ, D'Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA, Maski K, Nichols C, Quan SF, Rosen CL, Troester MM, Wise MS. Consensus statement of the American Academy of Sleep Medicine on the recommended amount of sleep for healthy children: methodology and discussion. J Clin Sleep Med 2016;12(11):1549–1561.1.0 INTRODUCTIONHealthy sleep requires adequate duration, appropriate timing, good quality, regularity, and the absence of disturbances and disorders. Sleep duration is a frequently investigated sleep measure in relation to health outcomes. Many studies have shown that adequate sleep duration is associated with better attention, behavior, cognitive functioning, emotional regulation, and physical health among children.1–3A panel of 13 experts in sleep medicine and research used a modified RAND Appropriateness Method4 to develop recommendations regarding the sleep duration range that promotes optimal health in children aged 0–18 years. The Consensus Recommendations5 were previously published, and this report expands on the methodology, results of the literature search, key findings from published research, overview of discussion by the panel members during the in-person meeting, and limitations of the process to answer the critical question: How much sleep is needed for optimal health in children?2.0 METHODSThe American Academy of Sleep Medicine (AASM) Sleep Duration Consensus Conference used a modified RAND Appropriateness Method (RAM)4 to establish consensus for the amount of sleep needed to promote optimal health in children and teenagers.2.1 Expert Panel SelectionIn accordance with the recommendations of the RAM, the Sleep Duration Consensus Conference panel comprised 13 voting members, including a moderator. All panel members are experts in sleep medicine and/or sleep science. The panel members were recommended by the Board of Directors of the AASM.Panel members were sent a formal letter of invitation from the AASM and were required to complete Conflict of Interest disclosures before being officially accepted. To avoid further conflicts, panel members were not permitted to participate in similar consensus activities by other organizations.2.2 Modified RAND Appropriateness MethodThe RAND Appropriateness Method uses a detailed search of the relevant scientific literature, followed by two rounds of anonymous voting to determine consensus on the appropriateness of a recommendation. The first round of voting is completed without panel interaction to prevent panel members from influencing each other's votes. The second round of voting occurs after a panel discussion of the available evidence and Round 1 voting results.In a modification to RAM, the Consensus Conference included a third round of voting, which considered all available evidence and the previous voting results, to establish a single recommendation for the amount of sleep needed to promote optimal health for each age group in children. The third round also involved a discussion of the merits of recommending an optimal sleep duration range versus a simple threshold value. The final Consensus Recommendations resulted from the third round of voting.The charge to the Consensus Conference panel was to determine a sleep duration recommendation for healthy children. Panel members voted on the appropriateness of one-hour increments ranging from < 6 to ≥ 18 hours of sleep. One-hour increments were selected because these were the most commonly reported units in epidemiologic and experimental studies. Substantial heterogeneity was present in the sleep duration assessment instruments. The consensus recommendations focused on overnight and daytime nap durations when appropriate as napping is considered biologically normal under the age of 7 years. The final recommendations were based on the one-hour values that were determined by the panel to be "appropriate" to promote optimal health in children.2.3 Detailed Literature Search and ReviewThe AASM Board of Directors charged the panel with developing a recommendation for sleep duration in healthy children. This charge coincides with the goals of the National Healthy Sleep Awareness Project (NHSAP) and with the Sleep Health Objective of Healthy People 2020 to "increase the proportion of students in grades 9 to 12 who get sufficient sleep."6The scope of the recommendation was limited to children aged 0–18 years. After a preliminary review of the literature, prior Centers for Disease Control and Prevention (CDC), AASM, and National Sleep Foundation (NSF) recommendations, as well as commonly frequented websites, the following age groups were created: < 12 months, 12 months to < 3 years, 3 years to < 6 years, 6 years to < 13 years, and 13–18 years. There was substantial overlap of age groups within the literature, and this was discussed during the in-person conference.A preliminary search of the literature and specific National Library of Medicine Medical Subject Headings (MeSH) terms identified several health outcomes that were most commonly examined in relation to sleep duration in children. Based on this evidence, the panel decided to focus on the relationships between sleep duration and the following 10 health categories: cardiovascular health, developmental health, human performance, general health, immunology, longevity, mental health, metabolic health, pain, and cancer.After establishing the health categories, a detailed literature search was performed in PubMed on October 1, 2015. The search terms used for the literature search are detailed in the supplemental material. The search was restricted to studies in human children ages 0–18 years, published in English, with no publication date limit. Case reports, editorials, commentaries, letters and news articles were excluded from the search results. The initial search produced 1,040 publications. The search results were reviewed based on title and excluded a priori for the following reasons: focus on sleep quality or fatigue instead of sleep duration, assessing sleep duration in specific disorders or sleep disorders, experiments on total sleep deprivation, children sleeping outside normal day/night sleep schedules, assessments of sleep deprivation as a treatment (insomnia or depression), and focusing on medication effects on sleep duration. Application of these restrictions resulted in 864 publications.The panel reviewed the abstracts of these remaining publications using the criteria described above. Citation pearl growing was used to capture additional important publications that were not identified by the search. Accepted publications were graded for quality using the Oxford criteria.7 All accepted publications were reviewed in detail and the data listed in Table 1 were extracted.Table 1 Data extracted from studies for evidence tables.Table 1 Data extracted from studies for evidence tables.Based on the data extraction, accepted studies were subdivided into the categories listed in Table 2.Table 2 Health domains.Table 2 Health domains.The extraction sheet and full text of all accepted publications were made available to the panel members for review. Each panel member was assigned to a particular health domain and asked to identify the most informative studies based on study design and evidence quality. After review of the literature, the domains of pain and cancer did not contain sufficient data to guide sleep duration recommendations and therefore were excluded prior to Round 1 Voting. After lengthy discussion at the conference, the domain of longevity was excluded prior to Round 2 Voting. A second PubMed literature search was performed during the conference on February 19, 2016 to collect more recent relevant studies.2.4 Round 1 VotingPrior to the conference, panel members reviewed the accepted publications and extraction sheets. Based on their review of this material and their clinical and research expertise, members voted to indicate their agreement with the following statement, "Based on the available evidence, [x] hours of sleep is associated with optimal health within the [x] category in the [x] age group." "Hours of sleep" was categorized as: < 6 hours, 6 to < 7 hours, 7 to < 8 hours, 8 to < 9 hours, 9 to < 10 hours, 10 to < 11 hours, 11 to < 12 hours, 12 to < 13 hours, 13 to < 14 hours, 14 to < 15 hours, 15 to < 16 hours, 16 to < 17 hours, 17 to < 18 hours, ≥ 18 hours. The panel members voted using a 9-point Likert scale, where 1 meant "strongly disagree," 9 meant "strongly agree," and 5 meant "neither disagree nor agree." Panel median values were placed into three broader categories, with the following interpretations: 1–3 indicated disagreement with the statement, 4–6 indicated uncertainty, and 7–9 indicated agreement with the statement.Panel members were instructed not to discuss the evidence or their votes with each other to ensure independence. Panel members' votes were collected by email and compiled to determine the median and distribution of votes. Individual results tables were created and distributed to the members at the consensus conference, displaying the distribution of votes (anonymously), the member's vote, and the median vote (Figure 1).Figure 1: Round 1 voting results.Round 1 voting was based on voting across all age groups under the following eight domains: cardiovascular health, developmental health, human performance, general health, immunology, longevity, mental health and metabolic health.Download Figure2.5 Conference Proceedings and Round 2 VotingPrior to the conference, panel members were selected to become domain experts for each domain. At the conference, members reviewed the results of Round 1 voting for a domain, and then the domain experts presented a review of the best available evidence for that domain. Panel members then discussed the results of Round 1 voting, the accepted publications for the domain and any other relevant evidence. After discussion, panel members completed Round 2 voting for the age groups within the domain, following the same procedures from Round 1 voting. The conference proceeded in this manner for each domain.2.6 Round 3 Voting and Development of RecommendationsPanel members reviewed and discussed Round 2 voting results for all domains and the entire body of accepted publications in preparation of voting on recommendation statements. After discussions concluded, panel members completed Round 3 voting for a single recommendation of appropriate sleep duration range for each age group, following the same procedure as for Round 1 and Round 2 voting, but with the following statement: "Based on the available evidence, [x] hours of sleep is associated with optimal health in [x] age group."Based on the results of Round 1 and Round 2 voting, the conference discussions, and with the agreement of all the panel members, the infant (0 to 12 months) category was reduced to 4 to 12 months. This decision was based on the lack of evidence in this 0–4 month old age group. Thus, no recommendations were made for children under 4 months of age for any of the categories.Upon completion of Round 3 voting, the panel members reviewed the voting results and developed the recommendations. The age groups and hour ranges were simplified to those presented in the consensus statements for the purposes of simplifying recommendations and ensuring clarity.The final recommendations were submitted to the AASM, Sleep Research Society (SRS), American Academy of Pediatrics (AAP), and American Association of Sleep Technologists (AAST) Boards of Directors for their endorsements.3.0 SUMMARY OF LITERATUREThe following sections summarize the key evidence considered by the panel in developing the recommendations while acknowledging that a complete evaluation of the evidence is beyond the scope of this consensus process.For each domain, the panel reviewed studies with children from all over the world, addressing sleep duration and health outcomes across the prespecified age ranges. Within each domain, there were topics without information for some of the age groups, and often studies spanned several of our prespecified age groups. Studies that assessed the relationship between sleep duration and the search term of interest were the most informative. Many studies reported more than one outcome. However, emphasis was placed on longitudinal or cross-sectional cohort studies that reported sleep duration in unselected general populations as well as smaller studies of unconstrained sleep in healthy children. Some studies only provided correlation or regression coefficients and thus were minimally informative. Others reported the association between general health and sleep duration, but only at a limited number of thresholds. In most studies, sleep duration was assessed by parent or child self-report. Polysomnographic data and actigraphy were considered when appropriate such as in studies of unconstrained sleep in the laboratory or at home. Systematic comparisons between studies were challenging and in most cases not possible. The following domains and information were reviewed.3.1 General HealthIn the general health domain, the number of children in each study ranged from less than 25 to over 74,000.Within the 4-months to < 12 months age range, there were few studies. However, two large prospective birth cohorts indicated that over a 24-hour period, healthy infants slept slightly > 13 to slightly > 14 hours.8,9 Furthermore, infants sleeping for lesser amounts of time had a greater likelihood of quality of life issues later in childhood.9For children in the 1 to < 3 years and 3 to < 6 years age ranges, there were only a small number of studies to review. One cohort study reported sleep durations between 11 and 12 hours in normal children.8 Limited data also suggested that sleeping less than 10 hours was associated with a greater risk of accidental injury10 and reduced quality of life several years later.11More studies were available that addressed general health outcomes in older children including those with polysomno-graphic data during unconstrained sleep.12,13 In the 6 to < 13 years age group, the panel observed that this was a period of rapid physical and mental development with more sleep appropriate for children at the lower end and less sleep for those at the higher end of the age range. Most informative was a large meta-analysis of children from 20 countries that indicated children between 9 and 12 years of age slept approximately 10 hours per night.14 In addition, data were available suggesting children sleeping 10 hours or more per night reported better health.15 In the 13–18 year age range, increased rates of injury were noted for those sleeping less than 7 or 8 hours16,17 and better health was reported for those sleeping 9 hours or more.15 A meta-analysis found that in teenagers, sleep declined continuously from between 9 and 10 hours at age 13 to between slightly less than 8 to slightly greater than 9 hours at age 18 years of age.15 Extended sleep duration was noted on weekends compared with weekdays.In summary, limited information indicates that there is a continuous decline in the amount of sleep required for normal general health. Lesser amounts are associated with poorer overall health and reduced quality of life later in childhood. However, there is little information regarding any impact of excessive sleep on overall health.3.2 Cardiovascular HealthMany of the studies in the cardiovascular domain examined the relationship between sleep duration and hypertension. Others looked at body mass index, waist circumference, serum lipids, C-reactive protein (CRP), and hemoglobin A1C (HbA1C). Most studies were cross-sectional, observational, retrospective or cohort design; none were randomized controlled studies. The number of participants varied from as few as 20 to just over 5,500. No studies in this domain included children younger than 5 years of age. Most studies focused on adolescents and teenagers.The majority of studies suggested a shorter sleep duration was associated with either an increased risk of hypertension or actual hypertension. However, the definition of "short/shorter" sleep was different between the studies. For children > 5 years, studies suggested a shorter sleep duration (< 10 hours,18 some < 9 hours,19 some < 8 hours,20,21 and one < 5 hours22) was associated with either an increased risk of hypertension or actual hypertension. One study showed an increased odds ratio of hypertension in girls who slept > 9.5 hours.23 Another study suggested that < 10 hours of sleep was associated with hypotension (systolic blood pressure < 100 mm Hg) in preschoolers.18 Conversely, there were also data to suggest no adverse effect of sleep characteristics on cardiovascular health.24–26In summary, evidence indicates that shorter sleep duration of < 5 hours is associated with increased risk of hypertension. However, there is some suggestion that in girls regularly sleeping more than 9.5 hours, hypertension risk is increased.3.3 Metabolic HealthMany studies in the metabolic domain specifically targeted the relationship between sleep duration and overweight/obesity. Other metabolic parameters studied included: waist circumference, insulin resistance (HOMA-IR), bone mineral content, triglycerides, C-reactive protein, HbA1c, leptin, and ghrelin. Most were cross-sectional studies of community-based populations. The number of participants in studies ranged from 62 to 81,390.Most studies demonstrated a negative association between sleep duration and overweight/obesity. Shorter sleep durations were also associated with increased risk for developing overweight/obesity. Two meta-analyses found sleep duration inversely correlates with obesity in children 0–18 years.27,28 For each hour increase in sleep, the risk of overweight/obesity decreased. Children under age 10 years show a more linear dose-response relationship of sleep duration and weight status. Additionally, there is evidence of a stronger inverse relationship for sleep duration and weight status in boys compared with girls.28A longitudinal study of 915 children aged 6 months to 3 years, showed infant sleep duration of less than 12 hours per day was associated with higher body mass index (BMI) z scores and increased odds of overweight during subsequent preschool years.29 Similarly, in a cohort study of 1,930 children ages 0–13 years, in younger children, ages 0–4 years, sleep duration of less than 11 hours was subsequently associated with increased risk of being overweight/obese. However for children ages 5–13 years, sleep duration was not associated with subsequent weight status.30 Other cohort studies report similar findings.31 A large cross-sectional study of 3,875 infants and 3,844 children (up to age 7 years) showed that sleep duration did not predict obesity; however, obese children ages 6 to 7 years were found to sleep approximately 30 minutes less than non-obese children.32 In a cross-sectional study of 1,229 children ages 5 to 11 years, children who slept less than 10 hours per weeknight were 5 times more likely to be overweight than those who slept at least 12 hours on weeknights.33 In another large cross-sectional study of 8,274 children ages 6 to 7 years old, children with sleep duration shorter than 10 hours had an increased odds ratio to develop obesity.34 In a cross-sectional study of 6,576 children, ages 7–11 years, children who slept < 9 hours per night had a higher risk for overweight, obesity, and abdominal obesity compared to children who slept 10–11 hours.35 In a study of 319 children ages 10–17 years, total sleep time was negatively correlated with overweight/obese status.36 Similar findings were observed in a larger cross-sectional study of 6,324 children ages 7–15 years. Boys who slept < 10 hours per night had increased odds of overweight compared to children sleeping > 10 hours.37 In 3,311 children 12.5 to 17.5 years, shorter sleep duration < 8 hours was associated with increased BMI, body fat, and waist and hip circumferences.38 A cohort study of 1,303 children aged 5–29 months showed that children sleeping < 10 hours per night consumed approximately 50 more kcal per day than children sleeping 11–12 hours,39 suggesting that changes in appetite may be a possible mechanism for a relationship between short sleep and weight status. Of note, one study of children ages 6–17 years reported no independent association between insufficient sleep and childhood obesity; however, no sleep duration information was provided by parents.40In terms of other metabolic parameters, in a cohort of 652 children, chronic short sleep duration was associated with higher waist circumference, higher insulin levels, and greater HOMA-IR attributed to adiposity.41 Higher HOMA Indices were also observed in high school-aged children who slept < 6.48 hours.42 In children ages 4–7 years, there was increased bone mineral content in children who slept longer than 8 hours.43A sample of 62 obese 8- to 17-year-old children studied with polysomnography (PSG) showed a U-shape curve for metabolic parameters such as HbA1c and insulin suggesting an ideal range of 7.5–8.5 hours of sleep for this group of children.44 A U-shape curve was also observed in a study of 387 children ages 13–17 years, where HOMA-IR was 20% higher when sleep duration was < 5 hours or > 10.5 hours.45Furthermore, higher C-reactive protein was observed in 13–17 year old children with < 9 hours sleep duration.46In summary, short sleep duration is associated with an increased risk for overweight/obesity, particularly in younger children < 10 years, and in boys. There is also evidence that short or long sleep duration is associated with disruption of other metabolic parameters including appetite and glucose/insulin metabolism.3.4 Mental HealthThe variables of interest in the mental health domain related to mood (e.g., depression, anxiety, suicidality, emotional regulation, irritability and self-esteem); risk-taking behaviors (e.g., drug use); problematic behaviors (e.g., defiance and tantrums); and attention-deficit/hyperactivity disorder (ADHD) symptoms (e.g., hyperactivity, impulsivity, and inattentiveness). Studies included approximately 100 to 30,000 participants.Limited data were available for children in the 4 months to less than 12 months age range. One study looked at the longitudinal sleep trajectories of approximately 3,000 children beginning at age 0–1 year with follow-up at age 6–7 years.9 Those children who were persistent short sleepers and poor sleepers had more difficulties with emotional, social and physical functioning at age 6–7 years when compared to "typical sleepers" who slept approximately 14.5 hours of sleep at age 0–1 year and 10.75 hours of sleep at age 6–7 years. Similarly, there were few studies on sleep duration and emotional/mental health within the 12 month to < 3 year old and 3 to < 6 year old age categories. One study collected almost 33,000 parental surveys regarding child sleep duration and the emotional and behavioral regulation of these children at 18 months and 5 years of age.47 Children who had short sleep duration of ≤ 10 hours at 18 months were at significantly greater risk of concurrent and subsequent incident emotional and behavioral problems compared to a reference group of children receiving at least 13 hours of sleep at 18 months.47Studies reviewed for children ages 6–13 years of age focused on associations between total sleep duration and affect, emotional regulation, irritability, relationships with peers/ family, and perceived health. Experimental studies of sleep restriction or sleep extension showed that participants sleeping more than 9 hours (mean 9.8 hours) had better emotional lability scores and less restless/impulsive behaviors per teacher reports compared to those sleeping an average of 8.4 hours.48 In a similar study, children with a mean of 9.3 hours of sleep had significantly higher positive affect scores and parent-reported emotional regulation compared to children sleeping a mean of 8.1 hours.49 In contrast, no group differences were detected in negative affective scores and child-reported emotional regulation ratings. In cross-sectional studies, data were more mixed. For instance, impulsivity scores were significantly higher among children ages 7–8 years sleeping < 7.7 hours compared to those sleeping > 7.7 hours, but no group differences were found in total ADHD global scores.50 Likewise, there were no relationships between children sleeping less than 10 hours and their affective scores or reported peer/family relationships, but those sleeping ≥ 10 hours reported better overall health.15In contrast, the literature review showed a clearer relationship between sleep duration and mental health among adolescents, 13–18 years of age. Adolescents sleeping ≥ 9 hours of sleep had significantly better life satisfaction scores, fewer general health complaints, and better quality relationships with family compared to those sleeping less.15 Of greatest concern in the adolescent population are associations between short sleep duration and suicidal thoughts/behaviors and substance abuse. In one cross-sectional survey of 27,939 adolescents, participants who slept 7–8 hours reported less feelings of hopelessness, less tobacco use, less alcohol use, less illicit drug use, fewer suicidal thoughts, and fewer suicidal attempts compared to participants who reported sleeping 6–7 hours per night.51 Of note, this study showed a negative correlation between more sleep and less concerning behaviors, but after 9 hours of sleep, an increase in these behaviors was noted. This finding suggests a U-shape curve to sleep among adolescents in which too little or too much sleep is associated with mental health problems and substance abuse. To this point, another study showed that teens sleeping ≤ 5 hours and ≥ 10 hours had more suicidal attempts than those sleeping 8 hours per night.52In summary, there are limited data for infants 4 months to 1 year, but based on the literature, 14.5 hours of sleep seems appropriate. Available longitudinal data on sleep duration for toddlers suggests that at least 13 hours of sleep are beneficial for future mental health outcomes. In school-aged children, there are conflicting data, but children sleeping at least 10 hours report less health complaints and children with < 8 hours of sleep have increased reports of ADHD behaviors. Experimental data suggest at lea