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Three Part Question

In [a child of any age] does [computer game playing before bed] [adversely affect sleep] ?

Clinical Scenario

You are a community paediatric registrar carrying out an outreach community clinic. You see a 12-year-old child who has difficulty settling down to sleep. You give his mother the usual sleep hygiene advice and discuss the importance of a good routine including having a period of ‘quiet time before lights out’. He currently plays computer games in his room before turning off the light. As part of your discussion you suggest that he stops playing computer games before bed. His mother, who is a staff nurse, asks what evidence there is to support this advice. You decide to examine the evidence.

Search Strategy

PubMed was searched using the terms ‘children’ [MeSH] AND ‘sleep’ [MeSH] AND ‘computer games’ [MeSH]. Twelve articles were found of which all the abstracts were read. Only two articles were found to be relevant and were therefore included. One was a randomised crossover trial and the second was a prospective uncontrolled observational study.
A BioMed search using the terms ‘children’ [MeSH] AND ‘sleep’ [MeSH] AND ‘computer games’ [MeSH] was carried out.

No relevant articles were found in the BestBETs or Cochrane libraries.

Search Outcome

Twenty-four articles were found of which all the abstracts were read. None of the articles were found to be relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Dworak et al, 2007	11 male children who had previously volunteered for the Healthy Sleep for Cologne Children study (mean age: 13.45±1.04 years)	Randomised crossover trial (level 2b)	Polysomnographic measurement of sleep architecture and sleep continuity	Computer game playing resulted in a shift in sleep stage (especially in stage 2), prolonged sleep onset latency and subsequent declines in verbal memory performance	Small study group
Van den Buick et al, 2004	2546 students from first- and fourth-year classes in 15 secondary schools in the Flemish community in Belgium (mean first year age: 13.16 years; mean fourth year age: 16.37 years). Data from the Leuven Study on Media and Adolescent Health	Prospective, uncontrolled observational study (level 2b)	Numbers of hours spent playing computer games, number of hours spent sleeping and tiredness factor	Children with a computer in the bedroom went to bed significantly later on weekdays and spent significantly less time in bed. They reported higher levels of tiredness	Self-reporting of time spent on computer and in sleep – may bias results

Comment(s)

Many newspapers and magazine articles mention the link between computer games and poor sleep, particularly in teenagers (Connor). We focused on whether having a computer in the bedroom, or playing computer games prior to bedtime, affected the quality and quantity of children's sleep. Much has been written about the type of children who are more likely to play computer games prior to sleep. These papers were excluded, as they had no relevant information about the impact of such activities on sleep itself.

Sufficient sleep is necessary for maintaining the body's homeostasis, as well as for fixing memories and learning (Maquet). Lack of sleep, as well as changes in sleep pattern, have been associated with numerous problems including daytime sleepiness (Saarenpää-Heikkilä), behavioural issues (including hyperactivity and poor concentration)(Stein) and accidents.

The two studies outlined in the table focus on the impact computer game playing has on the quality and quantity of sleep.

Dworak et al found that computer game playing resulted in a significant reduction in slow wave sleep, with a prolonged sleep onset latency of 10.83±8.33 min at baseline compared to 32.50±25.67 min after computer game playing (p<0.05) and a ‘shift’ in sleep stages with prolonged stage 2 non-rapid eye movement (non-REM) sleep.This led to less time in subsequent sleep (leading to midnight waking and reduced sleep quality). No effects on REM sleep were observed. Computer game playing resulted in a significant decline in verbal memory performance (but not visual memory), which could influence learning processes. Recently acquired knowledge is very sensitive to the subsequent consolidation period and it is thought that emotional influences, as may occur when playing computer games, within the hours after learning could influence memory consolidation considerably(Maquet, Stickgold).Other studies have found that a single night of restricted sleep led to impaired cognitive function in children, for example, regarding verbal creativity and abstract thinking (Randazzo).

Van den Buick used a standardised self-administered questionnaire quantifying: media presence in bedrooms (television or computer); volume of television viewing, computer game playing and internet use; time spent in bed on weekdays and at the weekend; and level of tiredness.It was found that children with a gaming computer in their bedroom went to bed significantly later on weekdays and spent significantly less time in bed on weekdays. Children who played more computer games also went to bed later at the weekend. As the measures of ‘media in the room’ and ‘media use’ were analysed separately, the overlap between the two blocks of data is unknown. In general, both groups spent less time in bed and reported higher levels of tiredness generally. This study found similar results between television watching and computer game playing.

Both studies showed that computer game playing has a significant impact on sleep by impairing the quantity and quality of sleep. Verbal cognitive performance can also be affected. Paediatricians need to consider this in their clinics when reviewing children and young people with daytime sleepiness (Saarenpää-Heikkilä) and behavioural concerns (including hyperactivity and poor concentration)(Stein).

Parents should be made aware of the potentially harmful effects of computer game playing (and other media consumption) on sleep in order to provide adequate guidance to their children.

Clinical Bottom Line

Computer game playing prior to sleep can impair the quality and quantity of sleep. (Grade B−/C)

References

1. Dworak M, Schierl T, Bruns T, et al . Impact of singular excessive computer game and television exposure on sleep patterns and memory performance of school-aged children. Pediatrics 2007;120:978–85.
2. Van den Buick J . Television viewing, computer game playing, and internet use and self-reported time to bed and time out of bed in secondary-school children. Sleep 2004;27:101–4.
3. Connor S . Mobile Phones and Video Games ‘Are Depriving Children of Sleep’. http://www.independent.co.uk/news/science/mobile-phones-and-video-games-are-depriving-children-of-sleep-574807.html 2004 (accessed 13 Jul 2011).
4. Maquet P . The role of sleep in learning and memory. Science 2001;294:1048–52.
5. Saarenpää-Heikkilä O, Laippala P, Koivikko M . Subjective daytime sleepiness in schoolchildren. Fam Pract 2000;17:129–33.
6. Stein MA, Mendelsohn J, Obermeyer WH, et al . Sleep and behavior problems in school-aged children. Pediatrics 2001;107:E60.
7. Stickgold R, Hobson JA, Fosse R, et al . Sleep, learning, and dreams: off-line memory reprocessing. Science 2001;294:1052–7.
8. Randazzo AC, Muehlbach MJ, Schweitzer PK, et al . Cognitive function following acute sleep restriction in children ages 10–14. Sleep 1998;21:861–8.