Sleep Disturbances and Executive Function in Childhood Neurodevelopmental Disorders: Clinical Assessment and Implications for Neuropsychological Intervention

Sandra Fonz Bujalance, occupational therapist, addresses the close relationship between sleep disturbances and executive function in children with neurodevelopmental disorders such as autism and ADHD.

We analyze sleep architecture and its impact on the maturation of prefrontal networks, detailing the specific clinical profiles associated with ADHD, autism, and language disorders. We provide key guidance for differential diagnosis and assessment protocols using tools such as the NEPSY-II battery, integrating interventions based on cognitive behavioral therapy and sleep hygiene. This is an essential technical guide for optimizing diagnostic accuracy and therapeutic efficacy in pediatric neurorehabilitation.

Why is sleep a critical variable in pediatric neuropsychological assessment?

Sleep is a daily biological activity that takes on particular importance during childhood development, as sleep disturbances can significantly affect cognitive and behavioral functioning and daily participation.

In pediatric neuropsychology, both sleep problems and executive function difficulties (generally associated with behavioral problems and/or academic performance) are common reasons for consultation in neurodevelopmental disorders. However, it is essential to recognize that both variables are closely related and mutually reinforce one another; therefore, they should be assessed together to avoid biased interpretations and taken into account when interpreting the results. 

Sleep acts as a modulating variable of cognitive performance, particularly affecting executive processes such as working memory, cognitive flexibility, and processing speed (Waters y Bucks, 2011).

Neurobiological foundations of sleep and its impact on executive functions in childhood

Sleep architecture progresses from a presleep state in early fetal development until it reaches adult sleep architecture at around age 3, in accordance with maturation of the Central Nervous System (CNS). Two major phases are distinguished: non-REM (NREM) sleep, which includes slow-wave sleep and plays a fundamental role in physiological restoration, and REM (Rapid Eye Movements) sleep, characterized by intense cortical activity (Falup-Pecurariu et al., 2021).

Sleep and development of prefrontal lobe networks

During sleep, neurochemical and neurophysiological processes essential to the structure, metabolism, and function of the frontal lobes are activated. These processes include mechanisms of synaptic plasticity, neurotransmitter regulation, and neural network reorganization. In childhood, all of these processes are relevant to the maturation of prefrontal networks involved in planning, inhibitory control, and emotional regulation.

Memory consolidation, inhibitory control, and emotional regulation

During NREM sleep, reactivation of hippocampal circuits occurs, promoting consolidation of declarative memory. In turn, REM sleep facilitates the integration and reorganization of information stored during wakefulness within broader cortical networks, contributing to emotional and procedural learning (Landmann et al., 2014).

Sleep deprivation and disruptions in executive networks

Lack of sleep significantly affects cognitive abilities and, consequently, everyday functioning.

Sleep deprivation is associated with a decrease in activity in the dorsolateral and orbitofrontal prefrontal cortex, explaining the impairment in decision-making, inhibitory control, and emotional regulation observed in children and adolescents with insufficient sleep, as well as a low level of arousal that does not respond to environmental stimuli in the same way (Angulo, 2025).

Sleep phenotype and the main neurodevelopmental disorders

Robinson-Shelton y Maslow (2016) found evidence that sleep disorders often occur as a comorbidity of one of the main neurodevelopmental disorders in childhood. However, this disruption of physiological functioning may also increase the symptoms of the neurodevelopmental disorder itself. This situation is also affected by primary pharmacological treatments, which may exacerbate and/or cause sleep disturbances.

Sleep disturbances in ADHD: latency, delayed phase, and nighttime awakenings

Attention-deficit/hyperactivity disorder (ADHD) has high comorbidity with sleep disorders because they share neurobiological mechanisms related to a delay in the onset of nighttime melatonin secretion:

The most common findings are an increase in nighttime awakenings (more than two during the night), early-morning awakening, and a decrease in total sleep time. Difficulty falling asleep is also common. 

These children often spend more time in bed, but their actual sleep is less efficient. They also show more movement during light sleep stages, with restless legs. Instability in circadian rhythms is common and leads to increased daytime sleepiness (Arboledas et al., 2014). 

Other sleep-related associations in this population include snoring and enuresis (Domínguez-Ortega y de Vicente-Colomina, 2006).

Sleep disturbances in autism: circadian rhythm and melatonin secretion

Children with autism spectrum disorder (ASD) commonly experience delays in sleep onset (sleep latency) of more than 30 minutes per night and/or frequent prolonged nighttime awakenings that may ultimately lead to waking. 

These abnormalities are associated with REM sleep and possible dysfunction of excitatory monoaminergic pathways, together with a delayed rhythm of melatonin release (a common deficiency of dopamine and/or ferritin) and lower production of melatonin, which may be related to nighttime awakenings. Sensory dysregulation should also be considered as a variable involved in sleep (Iannizzotto et al., 2013).

Sleep disturbances in developmental language disorder 

Evidence of sleep disturbances in neurodevelopmental disorders is common, but not specifically in DLD. However, recent studies report sleep problems in this diagnosis that may correlate with these children’s clinical symptoms. They appear to have faster frequencies during NREM sleep, inappropriate uses, a greater number of body movements, and a higher arousal index (Andújar, 2017).

Sleep disturbances in intellectual disability

In intellectual disability, the most frequent sleep disturbances involve sleep onset and maintenance, early awakenings, and daytime sleepiness, with disrupted sleep stages. In syndromes involving intellectual disability, such as Prader-Willi syndrome or Down syndrome, sleep apnea is a frequent disorder (Nieto del Rincón, 2017).

How to integrate sleep analysis into pediatric neuropsychological assessment

Tools for neuropsychological assessment of sleep

Neuropsychological assessment in childhood is a multimethod process requiring multiple informants: the family and the child. Sleep can be assessed as an independent variable, but it should be considered in order to accurately evaluate cognitive performance (Pérez-Jara y Ruiz, 2022). 

As a first step, it is essential to review the medical history and complete the interview with parents and/or guardians to learn about sleep routines, behavioral changes, and so on. The communication channel should also be adapted to the child in order to gather the child’s perceptions. Additional studies, such as polysomnography, may be required.

Assessment should combine clinical observation, standardized scales, and neuropsychological tests. Commonly used instruments include the Owens Sleep Habits Questionnaire (CHSO), Children’s Sleep Habits Questionnaire (CSHQ), Pittsburgh Sleep Quality Index (PSQI), and Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD). The NEPSY-II cognitive assessment is a highly valid option because it measures executive functions and other cognitive processes, allowing them to be linked to sleep disturbances.

Emotional assessment should not be overlooked, as emotional difficulties may be a cause and/or consequence of sleep disturbances and impaired cognitive functions, especially in the context of neurodevelopmental disorders, where there is a close interrelationship among emotional regulation, sleep patterns, and cognitive performance.

In conditions such as ADHD or autism spectrum disorder, difficulties with emotional self-regulation can exacerbate sleep problems, which in turn negatively affects attention, memory, and executive functions, creating a bidirectional cycle of impairment that must be addressed comprehensively.

Differential diagnosis: executive deficit or sleep deprivation

It is challenging to distinguish whether an executive deficit is caused by an executive disorder or is being modulated by a sleep disturbance. They often involve similar behaviors: attentional difficulties, impaired inhibition and impulse control, reduced processing speed, emotional dysregulation, and low frustration tolerance. 

To achieve a differential diagnosis, clinicians must investigate the quantity and quality of sleep, daytime sleepiness, medication side effects, and other disorders that could be affecting sleep.

Implications for neuropsychological intervention: optimizing executive functions through sleep-focused care

Sleep-focused care should not be considered an ancillary element of pediatric neuropsychological intervention, but rather a priority and cross-cutting therapeutic goal, especially for people with neurodevelopmental disorders. Evidence indicates that improving sleep quality and quantity can produce significant changes in executive performance, emotional regulation, and adaptive behavior.

Cognitive behavioral intervention strategies for sleep problems

Multimodal intervention programs based on cognitive behavioral therapy (CBT) are a first-line treatment approach for addressing sleep problems in childhood.

These programs include:

• Structured sleep hygiene. Establishing regular, predictable bedtime routines. Removing screens before bedtime, controlling environmental variables, and avoiding daytime sleep. 

• Behavioral techniques include gradual and/or controlled extinction for nighttime awakenings and positive reinforcement (for example, with a token economy) for following routines, as well as progressive exposure to sleeping alone.

• At the cognitive level, relaxation techniques adapted to age, body awareness training, and cognitive reduction strategies before sleep are proposed (Ma, Shi y Deng, 2018).

Pediatric neurorehabilitation for sleep problems

Through executive function training, specifically planning, it is possible to establish routines that improve sleep hygiene. This also helps reduce disorganization in daily routines and establish more stable sleep patterns and schedules that facilitate sleep cycles (Oropeza-Bahena et al., 2019).

Likewise, intervention targeting attention is crucial, as attentional difficulties are often worsened by daytime fatigue resulting from insufficient or poor-quality sleep. This fatigue directly affects cognitive performance, especially on tasks requiring sustained attention and inhibitory control, creating a negative feedback loop between sleep and everyday functioning.

In children, this may be observed, for example, in children who show greater irritability, difficulty sustaining attention in the classroom, increased impulsivity, or lower frustration tolerance after nights of inadequate sleep. Similarly, fatigue may present as apparent hyperactivity or disengagement, which can be mistaken for symptoms of neurodevelopmental disorders.

From this perspective, training in self-regulation and inhibition will allow greater self-control over factors that interfere with sleep, such as screen use before bedtime. Evidence indicates that exposure to electronic devices at night is associated with poorer sleep quality, longer sleep-onset latency, and shorter sleep duration, due both to cognitive stimulation and to blue light emission, which interferes with circadian rhythms (Hale y Guan, 2015).

Family psychoeducation

Families must be involved in the intervention for treatment to be more effective; therefore, they should receive training through psychoeducation. 

It is necessary to provide evidence-based psychoeducation about sleep disorders, their effects on cognitive, behavioral, and emotional functioning, and the most effective strategies for intervention in the family setting.

They should be trained in behavioral strategies to apply reinforcers appropriately, manage nighttime resistance, and establish consistent limits. 

It is also essential to create a trusting space where they can express concerns, frustrations, and fears. Chronic sleep disturbance in children often affects caregivers’ physical and emotional health, making it appropriate to include self-care, emotional regulation, and parental stress-management strategies (Ogundele y Yemula, 2022).

Conclusions: sleep as a cross-cutting modulator of executive performance in childhood neurodevelopmental disorders

Sleep is an essential neurobiological modulator of executive performance and daily functioning in childhood. It directly influences processes such as attention, working memory, inhibitory control, cognitive flexibility, and emotional regulation (Adams et al., 2001).

In neurodevelopmental disorders, sleep disturbances not only occur frequently as a comorbidity but may also intensify core symptoms and distort interpretation of the neuropsychological profile. Sleep deprivation or fragmentation can mimic or exacerbate executive deficits, producing more complex clinical presentations and increasing functional impact in academic, family, and social settings.

Therefore, pediatric neuropsychological assessment should systematically integrate analysis of sleep patterns as a modulating variable of cognitive performance. Ignoring this dimension may lead to overestimated diagnoses or less effective interventions.

From a therapeutic perspective, intervening on sleep does not merely mean improving nighttime rest; it means optimizing the neurophysiological conditions necessary for learning, self-regulation, and brain development. An interdisciplinary approach involves collaboration among professionals such as neuropsychologists, clinical psychologists, pediatric neurologists or neurologists, pediatricians, occupational therapists, speech-language pathologists, and professionals in the educational and social fields. Together with family psychoeducation and cognitive behavioral intervention for sleep problems, these are fundamental pillars of comprehensive neuropsychological intervention.

Ultimately, understanding sleep as a cross-cutting domain makes it possible to design more targeted, effective, and sustainable interventions, promoting more adaptive cognitive and emotional development in children with neurodevelopmental disorders.

References

• Adams, N., Strauss, M., Schluchter, M., & Redline, S. (2001). Relation of measures of sleep-disordered breathing to neuropsychological functioning. American Journal of Respiratory and Critical Care Medicine, 163(7), 1626–1631.
• Andújar, M.A. (2017). Análisis del sueño en niños con diagnóstico de trastorno específico del lenguaje (Doctoral dissertation, Universidad de Sevilla).
• Angulo, D. B. A. (2025). La privación del sueño y su impacto en la neurocognición: Un análisis de los efectos en la memoria, atención y emociones. Horizonte Académico, 5(1), 635–653.
• Arboledas, G. P., Andreu, M. M., & Marabotto, M. M. (2014). Alteraciones del sueño y TDAH o TDAH y alteraciones del sueño¿ existe relación?. Pediatría Integral, 668.
• Domínguez-Ortega, L., & de Vicente-Colomina, A. (2006). Trastorno por déficit de atención con hiperactividad y alteraciones del sueño. Medicina clínica, 126(13), 500-506.
• Falup-Pecurariu, C., Diaconu, Ș., Țînț, D., & Falup-Pecurariu, O. (2021). Neurobiology of sleep. Experimental and therapeutic medicine, 21(3), 272. https://doi.org/10.3892/etm.2021.9703 
• Hale, L., & Guan, S. (2015). Screen time and sleep among school-aged children and adolescents: A systematic literature review. Sleep Medicine Reviews, 21, 50–58.
• Iannizzotto, V., Paez, A., Zanin, L., Azpiroz, R., & De Bortoli, M. (2013). Hábitos de sueño y trastornos del espectro autista. Fundamentos en humanidades, 14(27), 159-173.
• Landmann, N., Kuhn, M., Piosczyk, H., Feige, B., Baglioni, C., Spiegelhalder, K., Frase, L., Riemann, D., & Nissen, C. (2014). The reorganisation of memory during sleep. Sleep Medicine Reviews, 18(6), 531–541.
• Ma, Z. R., Shi, L. J., & Deng, M. H. (2018). Efficacy of cognitive behavioral therapy in children and adolescents with insomnia: a systematic review and meta-analysis. Brazilian Journal of Medical and Biological Research, 51, e7070.
• Nieto del Rincón, P. L. (2017). Discapacidad intelectual. Fundamentos de Psicopatología.
• Ogundele, M. O., & Yemula, C. (2022). Management of sleep disorders among children and adolescents with neurodevelopmental disorders: A practical guide for clinicians. World journal of clinical pediatrics, 11(3), 239.
• Oropeza-Bahena, G., López-Sánchez, J. D., & Granados-Ramos, D. E. (2019). Hábitos de sueño, memoria y atención en niños escolares. Revista mexicana de neurociencia, 20(1), 42-49.
• Pérez-Jara, C., & Ruíz, Y. (2022). Evaluación neuropsicológica en niños con trastornos del neurodesarrollo. Revista Médica Clínica Las Condes, 33(5), 502-511.
• Robinson-Shelton, A., & Malow, B. A. (2016). Sleep disturbances in neurodevelopmental disorders. Current psychiatry reports, 18(1), Artículo 6.
• Waters, F., & Bucks, R. S. (2011). Neuropsychological effects of sleep loss: Implication for neuropsychologists. Journal of the International Neuropsychological Society, 17(4), 571–586.https://doi.org/10.1017/S1355617711000610 

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