Unrecognized Sleep Difficulties and Caregiver Awareness at School Entry: A Population‐Based Study of First‐Grade Children

BACKGROUND: Sleep difficulties are common in childhood and affect behavior, emotional regulation, and school functioning, yet are often unrecognized by caregivers. METHODS: This population-based, repeated cross-sectional study included 1168 first-grade children (6-7 years) in Évora, Portugal. Sleep was assessed using the Portuguese Children's Sleep Habits Questionnaire (CSHQ-PT) and a structured family questionnaire. Associations with sociodemographic and family factors were examined using multivariable logistic regression; short sleep duration was analyzed using penalized logistic regression. RESULTS: Across cohorts, 46%-49% of children met the criterion for clinically significant sleep disturbance (SDI ≥ 48). Bedtime resistance, daytime sleepiness, and sleep-related anxiety were the most prevalent difficulties. Fewer than 10% of caregivers reported sleep problems, even among affected children. Clinically significant sleep disturbance was associated with caregiver education and later dinner timing, while longer commuting distance was associated with short sleep duration. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Findings support brief sleep screening and family-oriented sleep health guidance at school entry. CONCLUSION: Many children begin primary school with unrecognized sleep difficulties, highlighting the value of integrating sleep health into early school health frameworks.