Association Between Sleep Disordered Breathing and Behavior in School- Aged Children: The Tucson Children's Assessment of Sleep Apnea Study

Qiuhong Zhao1, Duane L. Sherrill3, James L. Goodwin2, 3, Stuart F. Quan*, 2, 4
1 SIROW, College of Social and Behavioral Sciences, University of Arizona, AZ, USA
2 Arizona Respiratory and Sleep Disorders Centers and Department of Medicine, University of Arizona, AZ, USA
3 College of Public Health, University of Arizona, Tucson, AZ, USA
4 Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA

© 2008 Zhao et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: ( This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Division of Sleep Medicine, Harvard Medical School, 401 Park Dr., 2nd Floor East, Boston, MA 02215, USA; Tel: 617-998-8842; Fax: 617-998-8823; E-mail:


Study Objectives:

This study analyzed the association between the Respiratory Disturbance Index (RDI) and two behavior measures, the Conners’ Parent Rating Scale (CPRS-R) and the Child Behavior Checklist (CBCL) in schoolaged children to determine whether there is an optimal threshold of Sleep-disordered Breathing (SDB) associated with increased risk of behavior problems.


The Tucson Children ’s Assessment of Sleep Apnea Study (TuCASA) is an observational cohort study of 6-11 year old Caucasian and Hispanic children designed to assess the anatomic, physiologic and neurocognitive correlates of SDB. 403 children with both polysomnography (PSG) and behavioral data were included in this analysis. Three definitions of SDB were used: RDI independent of oxygen desaturation (RDI0), RDI with 2% oxygen desaturation (RDI2) and RDI with 3% oxygen desaturation (RDI3). T-scored behavioral data were dichotomized at a cutoff point of 65, a score indicative of moderate to severe clinical impairment. Logistic regression was used to access the risk associated with SDB.


The analyses conducted using three different definitions of RDI suggest that the likelihood of having a clinically significant CPRS-R or CBCL subscale score was not necessarily progressive or linear across RDI categories. Cutoff points and prevalences for each definition of RDI proposed to be indicators of clinically significant SDB were RDI0 ≥ 7 (19.38%), RDI2 ≥ 2 (29.38%) and RDI3 ≥0.5 (23.96%) events per hour of sleep. Behaviors such as CPRS oppositional, social problems, psychosomatic and CBCL somatic complaints, social problems and aggressive behaviors were found to be significantly associated with SDB.


This analysis found an increased risk of behavior problems such as somatic complaints, oppositional or aggressive behaviors and social problems associated with sleep-disordered breathing in school-aged children. RDI cut points for three definitions of SDB are proposed: 7 for RDI0, 2 for RDI2, and 0.5 for RDI3 respectively.

Keywords: Sleep disordered breathing, children, behavior problems.