Gabrielle Rigney

Never Enough Sleep: A Brief History of Sleep Recommendations for Children

BACKGROUND AND OBJECTIVE: There is a common belief that children are not getting enough sleep and that children’s total sleep time has been declining. Over the century, many authors have proposed sleep recommendations. The aim of this study was to describe historical trends in recommended and actual sleep durations for children and adolescents, and to explore the rationale of sleep recommendations. METHODS: A systematic literature review was conducted to identify recommendations for children’s sleep requirements and data reporting children’s actual total sleep time. For each recommendation identified, children’s actual sleep time was determined by identifying studies reporting the sleep duration of children of the same age, gender, and country in the same years. Historical trends in age-adjusted recommended sleep times and trends in children’s actual sleep time were calculated. A thematic analysis was conducted to determine the rationale and evidence-base for recommendations. RESULTS: Thirty-two sets of recommendations were located dating from 1897 to 2009. On average, age-specific recommended sleep decreased at the rate of –0.71 minute per year. This rate of decline was almost identical to the decline in the actual sleep duration of children (–0.73 minute per year). Recommended sleep was consistently ∼37 minutes greater than actual sleep, although both declined over time. CONCLUSIONS: A lack of empirical evidence for sleep recommendations was universally acknowledged. Inadequate sleep was seen as a consequence of “modern life,” associated with technologies of the time. No matter how much sleep children are getting, it has always been assumed that they need more.

Children's sleep needs: is there sufficient evidence to recommend optimal sleep for children?

It is widely recognized that sleep is important for childrens health and well-being and that short sleep duration is associated with a wide range of negative health outcomes. Recently, there has been much interest in whether or not there are sufficient data to support the specific recommendations made for how much sleep children need. In this article we explore concepts related to childrens sleep need, discuss the theory, rationale, and empirical evidence for contemporary sleep recommendations, and outline future research directions for sleep recommendations. If sleep is to be treated as a therapeutic intervention, then consensus guidelines, statements, and evidence-based best-practice documents are needed to underpin sleep recommendations for children.

Are sleep education programs successful? The case for improved and consistent research efforts

Sleep duration and quality are associated with a range of neuropsychological and psychosocial outcomes in children and adolescents but community awareness of this is low. A small body of literature on sleep education programs in children and adolescents delivered through school-based programs is attempting to address this. A review of the literature found only 8 studies and 4 pilot studies in abstract form. This paper presents these sleep education programs and evaluates their effectiveness. In general, findings suggest that when sleep knowledge was measured it was increased in most programs. However this did not necessarily equate to sleep behaviour change such as increased sleep duration or improved sleep hygiene. Reasons for this are discussed and may include motivation and readiness to change, salience to the individual, delivery, content, time allocation, or methodological underpinnings. This paper attempts to understand this and assess how best to improve future sleep education programs from a theoretical perspective. Specifically, it considers the theory of planned behaviour which may assist in ensuring maximum efficacy for the current and future development of sleep education programs.

Can a school-based sleep education programme improve sleep knowledge, hygiene and behaviours using a randomised controlled trial.

OBJECTIVES The present study investigated the effectiveness of a school-based sleep education programme in improving key sleep behaviours, sleep knowledge, and sleep hygiene. DESIGN AND METHODS A cross-sectional cluster-randomised controlled trial with two groups (Intervention and Control) and three assessment time points [baseline, immediately post intervention (6 weeks post baseline) and follow-up (18 weeks post baseline)] was employed. A total of 296 students (mean age = 12.2 ± 0.6 years; 59% female) from 12 schools in Adelaide, South Australia, were recruited, with 149 participants in the Intervention group and 147 in the Control group. The intervention consisted of four classroom lessons delivered at weekly intervals, followed by a group project on sleep topics, which students presented at a parental information evening. Sleep patterns were assessed objectively (actigraphy, n = 175) and subjectively (time-use recall, n = 251) at three time points. Sleep knowledge and sleep hygiene (n = 296) were also measured. RESULTS Generalised estimating equations were used to compare changes in the Intervention and Control groups. The programme increased time in bed by 10 min (p = 0.03) for the Intervention group relative to the Control group, due to a 10-min delay in wake time (p = 0.00). These changes were not sustained at follow-up. There was no impact on sleep knowledge or sleep hygiene. CONCLUSION Investment in the sleep health of youth through sleep education is important but changes to sleep patterns are difficult to achieve. More intensive programmes, programmes with a different focus or programmes targeting different age groups may be more effective.

Lessons Learned from Sleep Education in Schools: A Review of Dos and Don'ts.

STUDY OBJECTIVES Sleep duration and quality are associated with negative neuropsychological and psychosocial outcomes in children and adolescents. However, community awareness of this is low and sleep education programs in schools are attempting to address this issue. Several studies now exist assessing the efficacy of these sleep education programs for improving sleep knowledge, sleep hygiene and sleep patterns. This paper presents these sleep education programs, most particularly, it presents the strengths and weaknesses of the current available studies in the hope that this can identify areas where future sleep education programs can improve. METHODS A systematic search of all school-based sleep education studies in adolescents was undertaken. Studies were scrutinized for author, teacher and participant comment regarding strengths and limitations of each study, which were then extracted and summarized. RESULTS Two specific types of sleep education programs emerged from the review, those that sought to change sleep behavior and those that sought simply to disseminate information. Issues that dictated the strength or weakness of a particular study including who delivers the program, the theoretical basis, the tools utilized to measure sleep patterns, the content, and their capacity to engage students were assessed. Sleep education was considered important by teachers, students and parents alike. CONCLUSIONS Future sleep education programs need to take into account lessons learned from previous sleep education efforts in order to maximize the potential for sleep education programs to improve the sleep health of our young people. COMMENTARY A commentary on this article appears in this issue on page 595.

Cognition and objectively measured sleep duration in children: a systematic review and meta-analysis

BACKGROUND Sleep recommendations are widely used to guide communities on childrens sleep needs. Following recent adjustments to guidelines by the National Sleep Foundation and the subsequent consensus statement by the American Academy of Sleep Medicine, we undertook a systematic literature search to evaluate the current evidence regarding relationships between objectively measured sleep duration and cognitive function in children aged 5 to 13 years. METHODS Cognitive function included measures of memory, attention, processing speed, and intelligence in children aged 5 to 13 years. Keyword searches of 7 databases to December 2016 found 23 meeting inclusion criteria from 137 full articles reviewed, 19 of which were suitable for meta-analysis. RESULTS A significant effect (r = .06) was found between sleep duration and cognition, suggesting that longer sleep durations were associated with better cognitive functioning. Analyses of different cognitive domains revealed that full/verbal IQ was significantly associated with sleep loss, but memory, fluid IQ, processing speed and attention were not. Comparison of study sleep durations with current sleep recommendations showed that most children studied had sleep durations that were not within the range of recommended sleep. As such, the true effect of sleep loss on cognitive function may be obscured in these samples, as most children were sleep restricted. CONCLUSIONS Future research using more rigorous experimental methodologies is needed to properly elucidate the relationship between sleep duration and cognition in this age group.

A Systematic Review to Explore the Feasibility of a Behavioural Sleep Intervention for Insomnia in Children with Neurodevelopmental Disorders: A Transdiagnostic Approach

Children with neurodevelopmental disorders (NDD) are at high risk for sleep problems, especially insomnia. It is currently not known whether behavioural sleep interventions developed for typically developing (TD) children are effective for children with NDD, and if interventions need to be modified for each diagnostic group. The aim of this systematic review was to identify and evaluate commonalities, trends in outcomes, and the methodological quality of parent-delivered behavioural sleep interventions for children with NDD, specifically Attention-Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), Cerebral Palsy, and Fetal Alcohol Spectrum Disorder. Nine databases were searched. A total of 40 studies met eligibility criteria. The majority of studies were conducted with ASD and ADHD populations. Common sleep problems were evident across the NDD populations. The most frequently reported included bedtime resistance, night-waking, early morning awakening, and co-sleeping. The most common interventions used were implementation of healthy sleep practices, reinforcement, graduated extinction, and faded bedtime. All studies reported at least one behavioural treatment component as effective. Commonalities across NDD populations, as well as the TD population, for both sleep problems reported and behavioural interventions implemented, suggest the feasibility of developing a transdiagnostic behavioural sleep intervention suitable for children with a range of NDD.

Establishing normal values for pediatric nighttime sleep measured by actigraphy: a systematic review and meta-analysis

Background Despite the widespread use of actigraphy in pediatric sleep studies, there are currently no age-related normative data. Objectives To systematically review the literature, calculate pooled mean estimates of actigraphy-derived pediatric nighttime sleep variables and to examine the magnitude of change with age. Methods A systematic search was performed across eight databases of studies that included at least one actigraphy sleep variable from healthy children aged 0-18 years. Data suitable for meta-analysis were confined to ages 3-18 years with seven actigraphy variables analyzed using random effects meta-analysis and meta-regression performed using age as a covariate. Results In total, 1334 articles did not meet inclusion criteria; 87 had data suitable for review and 79 were suitable for meta-analysis. Pooled mean estimates for overnight sleep duration declined from 9.68 hours (3-5 years age band) to 8.98, 8.85, 8.05, and 7.4 for age bands 6-8, 9-11, 12-14, and 15-18 years, respectively. For continuous data, the best-fit (R2 = 0.74) equation for hours over the 0-18 years age range was 9.02 - 1.04 × [(age/10)^2 - 0.83]. There was a significant curvilinear association between both sleep onset and offset with age (p < .001). Sleep latency was stable at 19.4 min per night. There were significant differences among the older age groups between weekday and weekend/nonschool days (18 studies). Total sleep time in 15-18 years old was 56 min longer, and sleep onset and offset almost 1 and 2 hours later, respectively, on weekend or nonschool days. Conclusion These normative values have potential application to assist the interpretation of actigraphy measures from nighttime recordings across the pediatric age range, and aid future research.

Optimizing an eHealth insomnia intervention for children with neurodevelopmental disorders: a Delphi study

&NA; Insomnia, which is related to daytime deficits and is a common problem for children with neurodevelopmental disorders (NDDs), is often successfully treated with behavioral strategies. However, there are barriers to accessing these treatments, and there has been little research examining what these interventions need to be usable and effective. The goal of this study was to gain consensus from experts in the field on the key components of an eHealth, parent‐implemented, intervention program aimed at improving sleep in children with attention‐deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, and fetal alcohol spectrum disorder. This was achieved using the Delphi method, which involves asking participants to respond to open‐ended questions about a topic of interest and then, in iterative rounds, to rate the recommendations that were made by the group. In the current study, participants (27 responders in the first round, 21 in the second, and 18 in the third) rated a total of 131 recommendations. Of those 131 recommendations, 52 items had high importance and high consensus and were deemed to be priority items to consider for creating an eHealth, parent‐delivered, behaviorally‐based intervention for insomnia in children with NDD. Furthermore, 75% (n = 84) of the 112 recommendations from the first round were believed to be applicable across all 4 NDD groups, thus providing evidence of the potential for a transdiagnostic intervention.