Sleep. Eat. Perform?

ACADEMIC SUCCESS PLAYS AN IMPORTANT ROLE IN IMPROVING FUTURE LIFETIME OPPORTUNITIES. A LARGE BODY OF KNOWLEDGE HAS ACCUMULATED on the role played by sleep in improving basic processes associated with school performance, including executive functions (EF), learning, memory, and IQ.1 A separate collection of information on the connection between sleep and academic performance has also been gathered.2–4 Despite the mutual relevance of such studies, work on these topics has proceeded independently and very little information is available on the mechanisms underlying the sleep/academic success association. This is a major knowledge gap, because, until such information becomes available, an important method by which the academic performance of children might be improved remains overlooked. The study of Beebe and colleagues5 in this issue of SLEEP makes an important contribution in linking these bodies of literature. The authors use objective and subjective measures of cognition, academic performance, and sleep in children with sleep disordered breathing (SDB). They found that SDB affected school performance via real-life attention and learning problems, but could not confirm such association for objectively measured EF, attention, memory, and IQ. These findings reveal an important mechanism by which disrupted sleep is associated to academic performance, and raise important questions with respect to the experimental methods that should be considered in future studies studying the association between sleep and school performance. Academic success involves the ability to use cognitive skills in a school environment that is full of distraction. Like life, school is often messy and challenging. Hence, the ability to perform well in the face of multiple demands is at the heart of an ability to fulfill academic potential. When these very same abilities are being examined in the office (i.e., with a supportive examiner and in the absence of distractions), this might not reflect the reality of challenges posed to a child at school. Further, many of the cognitive processes that are being explored are sensitive, by definition, to the impact of stress, fatigue, and motivation. These situational factors vary among contexts and may mean that performance values obtained in an “office” and in a real-life environment (such as school) differ. Despite the element of subjectivity, parent- and teacher-based reports reflect the actual abilities of a child to function in the school environment. Hence, such reports are ecologically valid. The need to identify ways by which objective measures of cognitive functioning can be obtained in a real-life context lies at the heart of our future ability to further determine the impact of sleep on academic performance. Beebe et al.5 have taken an important first step toward a better understanding of the interplay between sleep, cognition, and academic performance in children. Yet, their study highlights another important methodological challenge; the determination of cause-and-effect with respect to the association between sleep and academic performance. Most prior studies are correlative, thus prohibiting the drawing of cause-and-effect inferences. It is necessary to conduct experimental studies examining the impact of controlled changes in specific sleep dimensions on particular cognitive processes relevant for school performance. This might be feasible in relation to dimensions of cognition that are affected by situational or short-term arousal fluctuations, and are reversible. An example is exploration of the impact of sleep duration (modifiable) on attention (also modifiable) in the classroom. However, to determine the impact of sleep on more permanent cognitive characteristics such as IQ, longitudinal designs applying objective measurements over time to children of various ages are needed.6 Such designs will further reveal the relative impact of sleep as a predictor of academic success. When results of such studies targeting specific cognitive domains are available, they could be used to design interventions specifically targeting modifiable sleep parameters that significantly impact academic performance. Another interesting finding in the Beebe et al. study5 was the lack of SDB group differences in performance on “office”-based measures of cognition. Given that the groups clearly differed in grade success, with the less severely affected children showing better academic performance, this is surprising. However, the study focused on obese children and adolescents with varying degrees of SDB. There is growing evidence that obesity not only features elevated calorific intake and poor weight management, but is also linked to adverse neurocognitive outcomes, specifically lower EF.7 Consistent with this notion, there is evidence that obese children are more impulsive than are normal-weight children, and have less cognitive control.8,9 If this happens in the presence of food, it might contribute to weight gain. Hence, an overlap may exist among cognitive processes affected by sleep disruption and those associated with obesity. It may be that executive functions were equally affected in the studied groups, as obesity levels were similar, thus explaining the small variability seen on EF measures. It might be that the added impact of sleep disruption was manifested at school where children with poorer sleep experienced more difficulty in attention regulation and organization beyond the already affected EF. Although the data of the present study do not allow testing of the hypothesis that EF were already (and equally) poor in all groups, the idea allows important questions on the interplay between sleep, cognition, and obesity, to be formed. Do cognitive mechanisms relevant to decision-making, self-control, and impulsivity, that are affected by sleep disruption, moderate both academic performance and increased obesity? This is an important question with a significant translational impact, and is of particular relevance to subjects in the age range of Beebe's study.5 Both weight gain/obesity and chronic sleep deprivation peak in adolescence. However, the interplay among these factors remains poorly understood, and no current translational work seeks to consider both issues. Future studies using the existing perspective to pursue a strong translatable research agenda are needed to increase our understanding of the impact of sleep on the critical developmental domains of weight regulation and academic performance. Beebe's study is an important step toward this process, and toward both basic and translational research on pediatric sleep, cognition, obesity, and development.

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