1. Socioeconomic Impact of
Pediatric Sleep Disorders
Kin M. Yuen, MD, MS*, Rafael Pelayo, MD
INTRODUCTION
It is difficult to determine the socioeconomic
impact of pediatric sleep disorders because one
needs to take into account not only the impact
over the lifespan of the child but also the impact
the disorders can have within the other family mem-
bers. Within every family unit, sleep disturbance of
the young tends to affect every member of that unit.
Whether it is a newborn, a new adoptee, a sleep-
over, or an individual who has taken ill, there is a
multiplier effect on everyone’s sleep and next day
function. This review concentrates on the pub-
lished data of known pediatric sleep disorders
and their economic impacts to date.
DIRECT HEALTH CARE COSTS
There are limited data on prospective health care
utilization by children affected by sleep disor-
ders. In 2013,1
an Australian cross-sectional
study that sampled “birth” cohort at ages 0 to
1 year, 2 to 3 years old, and “preschool” cohort
at ages 4 to 5 and 6 to 7 reported those that
exhibited sleep problems used more health care
compared with their peers. Federal Medicare
expenditure captured 98% of all children regis-
tered in Australia. Longitudinal Study of Austra-
lian Children evaluated 5107 children at ages
0 to 1 years in 2004, and 4606 of these children
at ages 2 and 3 in 2006. The older group looked
at 4983 children ages 4 and 5, and later, at ages
6 to 7. These children were compared with
matched controls within randomly selected
postal codes. Among all the subjects, 92% had
complete sleep and Medicare data. Of children
with reported sleep problems, the average addi-
tional annual health care costs at age 5 were
$141 and for age 7 were $43 (in 2012 Australian
dollars). Adjusting for confounders, the increase
in health care costs was $98 at age 5 and $18
at age 7. The estimated cost to the Australian
government was $27.5 million (95% confidence
interval [CI] $9.2 to $46.8 million). This same
group also studied the health care costs of chil-
dren up to age 7 with “special health care
needs,” with an estimated the additional costs
at $161.8 million.2
It would not be surprising
that children with both chronic sleep disorders
and additional special health care needs would
have higher health care utilization and accompa-
nying costs in any society.3
There are no commercial or financial conflicts of interest to declare for K.M. Yuen or R. Pelayo.
Stanford Sleep Disorders Clinic, Stanford University School of Medicine, 450 Broadway Street, 2nd Floor, Red-
wood City, CA 94063, USA
* Corresponding author.
E-mail address: kin.yuen@stanfordalumni.org
KEYWORDS
ADD/ADHD Restless legs/Periodic leg movements in sleep Pediatric OSA Parasomnia
Circadian rhythm disorder Insomnia Mood disorder Guardian/parental effect
KEY POINTS
Pediatric disorders tend to affect the immediate support unit, adults and children.
High costs for direct consumption of medical care are offset by early diagnosis and treatment of
pediatric sleep disorders.
Pediatric sleep disorders are underdiagnosed and undertreated.
Attention deficit hyperactivity disorder may result from insufficient or fragmented sleep.
Delaying school start time resulted in decreased car crashes in teen drivers and improved mood.
Sleep Med Clin 12 (2017) 23–30
http://dx.doi.org/10.1016/j.jsmc.2016.10.005
1556-407X/17/Ó 2016 Elsevier Inc. All rights reserved.
sleep.theclinics.com

2. The costs that were captured included Medicare
Benefit Schedule pays for non–hospital-based
medical practitioners, and Pharmaceutical Bene-
fits Schedule that pays for 83% of medication
costs.1
Parent or primary caregiver report of sleep
problems and frequency was used as dichoto-
mized variables: no/mild, moderate/severe. The
investigators stipulated that subjective percep-
tions by caregiver of a child having a sleep prob-
lem were the “driver” to seek medical care, and
more objective measures were not as cost-
effective for a large population based–outcome
measure. Within the “baby” cohort, the need for
“specialized health care” almost doubled the in-
fants that were not reported to have sleep prob-
lems: 9.9% as compared with 5.3%. The
prekindergarten cohort similarly showed 21.2%
usage of specialized health care compared with
12.1% of those without sleep problems. The na-
tures of sleep problems were not reported, howev-
er. At age 0, 17.7% of children had “moderate/
severe” sleep problems, whereas 7% did at age
7. However, because medical diagnoses were
not captured in the analysis, those children with
developmental and neurologic challenges might
have skewed the usage of benefits and exhibited
more sleep problems overall. Nonetheless,
assessing overall sleep behavior at birth may
help predict those children potentially requiring
more medical attention subsequently.
An American study4
evaluated socioeconomic
conditions of sleep for 276 children in 133 girls
with a mean age of 9.44 years (SD 0.71). Because
of prior reports that children in poorer socioeco-
nomic strata had shorter sleep duration per
parental report, parents were interviewed on the
telephone regarding their family income level, part-
ner status (single, married), educational level, and
whether the child was residing with one or more
than one biological parent or other family member
who was not a parent. Sleep was estimated using
actigraphy on nondominant wrists for 7 consecu-
tive nights. “Lower maternal perceived economic
well-being predicted shorter sleep duration and
greater variability in sleep onset in children.” In
addition, when the caregiver had lower educa-
tional level, the child had lower sleep efficiency.
This study found different results with African
American compared with European and American
children, suggesting that ethnicity may be a signif-
icant moderator in the impact of sleep disorders.
BEHAVIORAL SLEEP PROBLEMS
An estimate of 20% to 30% of infants, toddlers,
and preschoolers may present with behavioral
challenges in going to sleep and repeated
awakenings according to a 2006 review.5
A report
by in 2014 by Meltzer and colleagues3
showed
only 5% of representative samples of pediatric
and adolescent patients that reported sleep
problems or were diagnosed with a sleep disorder
actually received sleep-related treatment recom-
mendation. Only 8% of children diagnosed with
sleep disorders and 2% identified with sleep prob-
lems received “any type of treatment recommen-
dation.” Of 750 children that had well-child visits
in urban and suburban primary care settings in
Philadelphia, 520 youth (69%) year 1, 490 youth
(65%) year 2, and 451 youth (60%) year 3 had
documented follow-ups from 2007 through 2010.
Of these, 150 were randomly selected, and the
average age was 6.21 years (SD 5.4; range
0.28–18 years). More sick visits and calls were
incurred among children that had sleep disorders
(mean 8.84; 95% CI 7.77–9.90) than those without
(mean 6.34; 95% CI 5.56–7.12). Up to one-third of
children showed persistence of sleep problems
“across time.” The families with lower income
tended not to have follow-up visits. These results
point to how difficult it is to accurately estimate
the socioeconomic impact to society of sleep dis-
orders in children.
ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER
The socioeconomic impact to society of attention-
deficit/hyperactivity disorder (ADHD) in children is
large.6,7
In the US educational system, a student
with ADHD incurred an average annual incremental
cost to society of $5007 according to a 2011 report.7
In 2016, the cost of medication was estimated at
$1669 per child. Sleep problems in this population
are very prevalent.8–12
The socioeconomic impact
of ADHD is not a problem just in the United States;
there is a rich international ADHD literature docu-
menting the impact of this condition. Sung and col-
leagues13
conducted a cross-sectional study in
outpatient clinics of pediatric hospitals, private pedi-
atric practices, and ADHD support groups to eval-
uate the prevalence of sleep problems among
children with ADHD in Victoria, Australia. Among
children that were identified to have sleep problems,
these children missed or were tardy for school more
than their peers without sleep problems. Of 330 fam-
ilies, 239 (74%) completed the survey. Sleep prob-
lems were classified as “mild” for 28.5%, and
“moderate or severe” for 44.8%. In 2006, caregivers
of children between 5 and 18 years completed a sur-
vey for the previous 4 weeks with the question, “Has
your child’s sleep been a problem?” The answers
were categorized as “none,” “mild,” or “moderate/
severe.” Problems surveyed included “difficulty
Yuen Pelayo24

3. falling asleep, resisting going to bed, tossing or
turning in bed, snoring or difficulty breathing, waking
up frequently during the night, difficulty getting up in
the morning, and tiredness on waking.” Most chil-
dren were boys: 90.4%, and lived with 2 caregivers
(76.6%). Including all sleep problems from mild to
moderate/severe, the prevalence was 73%. There
was a larger than expected report of difficulty falling
asleep: 71% in the mild group, and 84% in the mod-
erate/severe group. Among children with moderate
to severe sleep problems and ADHD, the caregivers
were 2.7 times more likely to be “clinically
depressed, stressed, or anxious” than the families
with children without any sleep problems (odds ratio
2.72; 95% CI 1.33–5.54). More importantly, only
45% of caregivers reported being asked about the
sleep of their children, and 60% received advice
about treatment.
When considering the socioeconomic impact of
sleep disorders in the children with ADHD, it is
important to point out that treatment of the sleep
disorders has been repeatedly shown to improve
the ADHD symptoms and would be expected to
therefore lower these costs.14–17
In addition,
because ADHD can persist into adulthood, treat-
ing sleep problems in children with ADHD should
be expected to have long-term societal benefit.
SLEEP DEPRIVATION/RESTRICTION
The most common cause of death among teen-
agers in the United States is automobile accidents,
and sleep deprivation appears to play a role. Marti-
niuk and colleagues18
reported in JAMA Pediatrics
in 2013 that, among 20,822 newly licensed drivers
from ages 17 to 24 in Australia, those who slept
less than 6 hours per night tended to have more
“off the road” crashes (relative risk [RR] 1.21;
95 CI 1.04–1.41), and these accidents occurred
more often from 8 PM to 11:59 PM (RR 1.86; 95%
CI 1.11–3.13). This prospective study followed pro-
visional drivers for 2 years and documented 19,327
subjects that had full crash reports. For 2015,
27.3% of students reported having 8 or more hours
of sleep during school nights. More male students
(median 29.3%; range 18.9%–41.5%) than female
students (median 23.6%; range 16.2–34.7)
had 8 or more hours of sleep.
The results of sleep restriction studies and behav-
ioral correlates were more difficult to define. Fallone
and colleagues19
enrolled 82 subjects (46 boys, 41
girls) ages 8 to 15 years (8.6–15.8 years; mean
11.9, SD 1.6 years) to examine the effects of sleep
restriction versus “optimized” sleep and their
behavior. After 5 nights of baseline sleep by actigra-
phy of at least 10 hours’ sleep, they were randomly
assigned to overnight stay for optimized sleep
(10 hours per night: n 5 42; 24 boys and 18 girls)
or restricted sleep (4 hours per night: n 5 45; 22
boys, 23 girls). Behavior, performance, and sleepi-
ness were assessed the following day. Although
sleep restriction was associated with shorter day-
time sleep latency by Multiple Sleep Latency Test,
increased subjective sleepiness by visual analogue
scales, and increased sleepy and inattentive be-
haviors, it was not associated with increased
hyperactive-impulsive behavior or impaired perfor-
mance on tests of response inhibition and sustained
attention. (Assessment tools used included the
Child Attention Profile, the Restricted Academic Sit-
uation, the Gordon Diagnostic System, and behav-
iors by trained observers.)
However, a more recent study of Korean high
school students by Lee and colleagues20
found
that among 50 students (10 males, 40 females
17.56 Æ 0.47 years old) who had “behaviorally
induced insufficient sleep,” as compared with 51
students (16 males, 35 females, 17.66 Æ 0.54 years
old) that had adequate nocturnal sleep, the students
with less sleep had poorer academic performance,
higher degree of impulsivity, and depression.20
Criteria for “insufficient sleep” group were: (1) sleep
duration on weekdays less than or equal to 7 hours;
(2) weekend oversleeps greater than or equal to
3 hours; (3) severe daytime sleepiness (Epworth
Sleepiness Scale [ESS] !10). The “adequate” sleep
group contained (1) sleep duration on weekdays
greater than or equal to 5 hours; (2) weekend over-
sleep less than or equal to 2 hours; (3) no significant
daytime sleepiness (ESS 7); and (4) the absence of
significant insomnia. Given these criteria, one can
argue that even with sleeping in for non–school
days for the “adequate” sleep group, the better per-
forming group itself did not get adequate sleep for
their age ranges because the expected total sleep
time is 8 to 9 hours per night.
To test the hypothesis that improving students’
sleep time will improve their overall performance,
a study by Vorona and colleagues21
looked at the
number of crashes in a 2-year follow-up study of
adjacent counties after one county had purposely
delayed the high school start time by 1 hour.21
The teens that resided in one county with earlier
start time of 7:30 AM (Chesterfield County) had
48.8/1000 crashes per licensed drivers versus the
later start time county of 8:30 AM (Henrico County),
which had 37.9/1000 (P 5 .04) for the year 2009 to
2010. For the next year 2010 to 2011, the teens 16
to 17 years residing in the county with the earlier
start time again had statistically significant higher
crash rate (53.2/1000 vs 42.0/1000), although not
for the whole group of ages of 16 to 18 year olds.
Meanwhile, the adult crash rates and the traffic
congestions did not differ between counties.
Socioeconomic Impact of Pediatric Sleep Disorders 25

4. Wahlstrom22
had reported that, by delaying high
school start times from 7:30 to 8:30 AM for the fall of
1997 to 2001 9th to 12th grade students in Minne-
apolis School District got 5 more hours of sleep
per week, improved attendance, and had fewer
symptoms of depression. There were 467 high
school students with 8:30 AM start time, and 169
students with 7:30 AM start time during this com-
parison. Subjective rated sleepiness in class
improved, and days “home sick from school”
were statistically significant. Improvements in
grades showed a positive trend, but not statisti-
cally significant compared with 3 years prior and
3 years after the intervention.
Owens and colleagues23
also studied the delay in
start time from 8 AM to 8:30 AM for 201 high school
students for grades 9 to 12 in Rhode Island for an in-
dependent school. The students having less than
7 hours of sleep decreased by 79% (from 33.8%
to 7.0%); students getting at least 8 hours of sleep
increased from 16.4% to 54.7%, but only 11%
were getting the recommended 9 or more hours.
Dr Owens and the Adolescent Working Group24
in its position paper for the American Academy of
Pediatrics issued worldwide epidemiologic review
of the lack of adequate sleep of teenagers, and the
potential role of later start time for high school or
secondary schools.24
Future prospective studies and sleep tracking
devices will likely help provide better data of the
extent of sleep loss among youth and the health
costs and benefits of adequate sleep time. Chang-
ing school start times would be expected to have a
significant socioeconomic impact that should
improve the quality of life for these children, their
families, and communities.
PEDIATRIC OBSTRUCTIVE SLEEP APNEA
It has been estimated that prevalence of pediatric
obstructive sleep apnea (OSA) is 1% to 4%.
Because children with OSA may become adults
with OSA, one can attempt to project the socio-
economic impact of OSA in children by looking
at the adult data. A most recent commissioned
report for the diagnosis and treatment of OSA con-
ducted by Frost and Sullivan (www.aasmnet.org/
sleep-apnea-economic-impact.aspx), and spon-
sored by the American Academy of Sleep Medi-
cine, surveyed 506 adults online with a diagnosis
of OSA. Research also included “100 leading
studies on the impact of the condition on every-
thing from heart attack risk to employee absen-
teeism for the cost benefit analysis.” The age
ranges of respondents were 3% of 18 to 29 years
old, 15% 30 to 49 years old, 56% 50 to 69 years
Epidemiology. (Ó American Academy of Sleep Medicine 2016.)
Yuen Pelayo26

5. old, and 26% 70 to 89 years old. The average age
of diagnosis and treatment was 53 years. Only an
estimated 12% of the population that has OSA
symptoms have been diagnosed. Diagnostic mo-
dalities included were in-laboratory polysomnog-
raphy, home sleep studies, continuous positive
airway pressure (CPAP) titration studies as generic
for all titration studies (although not separated into
in-laboratory or at home), and clinic visits.
Modeling treatment options, such as CPAP, oral
appliance, surgery, and lifestyle modifications, it
found that diagnosing and treating OSA resulted
in potentially $100.1 billion savings.25
Surgical
costs included bariatric, nasal “reconstruction,”
“maxillary/genioglossus/hyoid advancement,”
tongue-base reduction, adenotonsillectomy, hy-
poglossal nerve stimulation, pillar procedure,
sclerotherapy, and tracheostomy.
Economic costs included: (1) direct costs of
treatment of comorbid conditions, such as hyper-
tension, diabetes mellitus, obesity, depression,
medication and substance use, both as direct uti-
lization of medical care and as undiagnosed and
untreated individuals’ potential continuation of
medical expenses; (2) indirect annual costs for
traffic fatalities from drowsiness and commercial
truck driver accidents as well as calculated annual
costs from undiagnosed OSA drivers; (3) indirect
Diagnosing and treating all 29.4 M Americans with OSA could save $100.1 billion. (Ó American Academy of Sleep
Medicine 2016.)
Three sources of cost for diagnosed/treated OSA. (Ó American Academy of Sleep Medicine 2016.)
Socioeconomic Impact of Pediatric Sleep Disorders 27

6. costs of workplace accidents based on data of
daylight savings time estimates in 2009 of 5.7% in-
crease in injuries, and 67.6% “increase in days of
work lost due to sustained injuries,” opportunity
costs of absenteeism, and lost wages. Additional
cost savings in improvement of mood, productiv-
ity, and lessened medical costs were input into
costs calculations for workplace savings.
Benefits accrued included quality-of-life mea-
sures, gain in productivity (less workplace accidents
and injuries, decrease in days out from medical
illness and fatigue, clinic visits, disability), decrease
in traffic accidents, decreased medical expenditure
in direct utilization of medical services, decreases in
consumption of medications and substances such
as alcohol, cigarettes, and sleeping pills, and im-
provements in mood and relationship with partners.
Insomnia often accompanies OSA patients with
sleep fragmentation, and this study included the
costsof substance usedto treat insomnia into its es-
timates. Treatment of adults’ OSA lessened the
number of days absent from 6.3 to 4.5 per year.
Although the risks of hypertension, workplace ac-
cidents, and driving accidents are lower for children,
the risks of inattention, inopportune naps leading to
decreases in learning, and accidents in schoolyard
or sports-related injuries have not been yet been
fully captured. Data on sleep deprivation and its
costs have been reported earlier (see section on
attention deficit disorder (ADD)/ADHD). Bariatric
surgery data have supported its role in the treatment
of older teenagers who are morbidly obese and suf-
fer from OSA and comorbid conditions. Sleep disor-
ders of the young affect the entire family unit. Based
solely on direct medical costs alone, the conserva-
tive measure of 1% prevalence is considerable.
Because of the current obesity epidemic
affecting children and young adults, the prevalence
is expected to increase further. The 2015 survey
data from the Centers for Disease Control and Pre-
vention estimated 13.9% of American youths are
obese.26
However, further longitudinal studies will
help shed light on cardiovascular risks. The health
burden of comorbid diabetes has been studied.
INSOMNIA
Owens and colleagues27
published a national sur-
vey for pharmacotherapy for insomnia among
child psychiatrists in 2010. The ages of children/
adolescents were reported as 6 to 10 years, 10
to 20 years, and greater than 20 years. A surpris-
ingly wide range of medications were being
prescribed and recommended with little
evidence-based data to support it. The investiga-
tors concluded that insomnia is a significant clin-
ical problem in children treated by child
psychiatrists for a variety of behavioral, neurode-
velopmental, and psychiatric conditions. In addi-
tion, there was a worrisome, highly variable
clinical approach to insomnia in children.
Improving the sleep of infants can improve the
maternal well-being and lower the cost of health
care utilization. This was demonstrated in an
Australian study that offered behavioral interven-
tions to infants whose mother complained of
poor sleep at 7 months of age. Follow-up at 10
and 12 months showed improved maternal
mood, overall health, and lower medical costs.28
Oneofthechallengesofconfrontingthesocioeco-
nomic impact of sleep disorders in children is the
sense that not only is it an immense problem that is
hard to define but also the treatments are expensive
and labor intensive. However, when it comes to
adolescent insomnia that is not true, and perhaps
one should not be surprised that technology offers
a cost-effective solution. Cognitive behavioral ther-
apy(CBT)isunquestionablythebesttreatmentavail-
able for chronic insomnia.29
A study using online
CBT has proven that it can be effective, affordable,
and readily available.30
In this study, teenagers with
insomnia were randomized to either face-to-face
CBT sessions or Internet-based CBT sessions.
Both groups improved when re-evaluated after
1 year, but the Internet group had lower costs.
Over time, as the cost of manpower increases and
cost to access the Internet decreases, the advan-
tagesofInternet-based CBT should be even greater.
RESTLESS LEG SYNDROME
Restless leg syndrome (RLS) is a common but
underrecognized condition in children.31,32
It is a
familial disorder, so many of the children may
have parents or other family members that are
not aware that their episodic discomfort is a neuro-
logic condition with a name and is readily treat-
able.33
The authors were unable to locate any
publications of the socioeconomic cost of RLS
specifically for the pediatric population. However,
there have been analyses done of the costs in
adults, which can provide a sense of the potential
costs in a pediatric population. RLS has a preva-
lence ranging from approximately 2.5% to 10%
and is associated with reductions in quality of life
similar to or greater than those seen in patients
with other chronic conditions such as type 2 dia-
betes or osteoarthritis.34
A study of the direct eco-
nomic burden of RLS among patients treated with
dopamine agonists in a large US managed care
system was reported in 2012.35
The mean all-
cause health care costs were $11,485 per patient,
“mostly due to multiple medical conditions occur-
ring with RLS.” The actual RLS-related costs were
Yuen Pelayo28

7. only 6.7% of total all-cause costs. The investiga-
tors found that the relatively low costs associated
with RLS treatment should encourage expanding
the coverage of treatment to reduce the suffering
and costs associated with RLS.35
The socioeconomic impact needs to factor in
not only the health care utilization costs but also
indirect costs, primarily due to productivity los-
ses, which are as high as 20% in RLS patients.36
The humanistic burden of RLS with regard to
health-related quality of life, work productivity
loss, health care resource use, and direct and in-
direct costs has been studied using a large na-
tional survey.37
RLS patients were matched
on demographic and health characteristics to
non-RLS. RLS patients had significantly lower
health-related quality-of-life scores, including
mental component summary, physical compo-
nent summary, health utilities, and higher levels
of work productivity loss in the past 7 days, and
overall productivity loss as well as general activity
impairment. RLS patients had significantly higher
health care resource use in the past 6 months
than non-RLS patients: health care provider visits
and hospitalizations. Furthermore, the study
found that, across outcomes, increasing severity
is associated with increased economic and hu-
manistic burden for RLS patients.37
Considering how overwhelming the data are on
the large socioeconomic impact of RLS in adults,
how this affects children must be looked into
more closely. RLS may be misdiagnosed as
ADHD, which further adds to the socioeconomic
impact of this condition in children.32
Primary
care providers, and especially pediatricians,
should keep in mind the possibility of RLS being
present in any child with behavioral or sleep
problems. Accurate diagnosis and successful
treatment will undoubtedly improve the socioeco-
nomic burden of this condition.
SUMMARY
Although difficult to quantitate with current available
data, the socioeconomic impact of sleep disorders
in children is large and will grow unless steps are
taken to recognize and treat these disorders sooner.
Childrenwithsleepdisorderswilloftengrowuptobe
adults with sleep disorders and may go on to have
children of their own, also with sleep disorders. On
any given day, a clinician may hear a patient say,
“everybody inmyfamily snorers,”“my motherwould
never sleep at night,” “ my father always woke up
feeling tired,” “ my kids are night owls like me,” or “
“I thought everybody has to rub their legs at night.”
Sleep disorders are not mere nuisances. The data
presented in this review show lost productivity,
decreased quality of life, and increased health care
utilization are occurring currently in society because
of these often readily treatable conditions. Recog-
nizing and treating these conditions in children will
lead to a net improvement for all of us.
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