Jodi A. Mindell

Developmental aspects of sleep hygiene: Findings from the 2004 National Sleep Foundation Sleep in America Poll

OBJECTIVE To examine the associations between sleep hygiene and sleep patterns in children ages newborn to 10 years. The relationships between key features of good sleep hygiene in childhood and recognizable outcomes have not been studied in large, nationally representative samples. PARTICIPANTS AND METHODS A national poll of 1473 parents/caregivers of children ages newborn to 10 years was conducted in 2004. The poll included questions on sleep hygiene (poor sleep hygiene operationally defined as not having a consistent bedtime routine, bedtime after 9:00 PM, having a parent present when falling asleep at bedtime, having a television in the bedroom, and consuming caffeinated beverages daily) and sleep patterns (sleep onset latency, frequency of night wakings, and total sleep time). RESULTS Across all ages, a late bedtime and having a parent present when the child falls asleep had the strongest negative association with reported sleep patterns. A late bedtime was associated with longer sleep onset latency and shorter total sleep time, whereas parental presence was associated with more night wakings. Those children (ages 3+) without a consistent bedtime routine also were reported to obtain less sleep. Furthermore, a television in the bedroom (ages 3+) and regular caffeine consumption (ages 5+) were associated with shorter total sleep time. CONCLUSIONS Overall, this study found that good sleep hygiene practices are associated with better sleep across several age ranges. These findings support the importance of common US based recommendations that children of all ages should fall asleep independently, go to bed before 9:00 PM, have an established bedtime routine, include reading as part of their bedtime routine, refrain from caffeine, and sleep in bedrooms without televisions.

Relationship between child sleep disturbances and maternal sleep, mood, and parenting stress: a pilot study.

Although sleep disturbances in children are common, little is known about the relationship between childrens sleep disruptions and maternal sleep and daytime functioning. Forty-seven mothers completed measures of sleep, depression, parenting stress, fatigue, and sleepiness. Significant differences in maternal mood and parenting stress were found between mothers of children with and without significant sleep disturbances. Regression analyses showed that the quality of the childrens sleep significantly predicted the quality of maternal sleep. In addition, maternal sleep quality was a significant predictor of maternal mood, stress, and fatigue. Results from this pilot study support the need for future research examining the relationship between child sleep disturbances and maternal daytime functioning, and they highlight the importance of screening for and treating pediatric sleep disruptions.

Sleep and sleep ecology in the first 3 years: a web‐based study

This study was designed to provide data on sleep patterns during the first 3 years, based on a large US–Canada Internet sample, to assess the prevalence of parental interventions and related factors of infant sleep ecology and to evaluate the links between sleep ecology and sleep. Five thousand six parents completed a web‐based online questionnaire about their children, aged from birth to 36 months. The questionnaire included items pertaining to sleep patterns, sleep environment, sleep‐related parental interventions, sleep position, and demographic information. The results reflected clear sleep‐related developmental changes including a decrease in daytime sleep and total sleep time, as well as consolidation of sleep during the night, which was manifested in a decrease in night wakings and nocturnal wakefulness. Sleep ecology and parental behaviors significantly explained a portion of the variance in the child’s sleep patterns. Parental interventions that encourage independence and self‐soothing were associated with extended and more consolidated sleep, especially in comparison to more active interactions that were associated with shorter and more fragmented sleep. These findings provide parents and professionals reference data for assessing sleep in young children. Furthermore, the results provide information on specific ecological factors that are associated with increased risk for sleep problems.

Cross-cultural differences in infant and toddler sleep

BACKGROUND To characterize cross-cultural sleep patterns and sleep problems in a large sample of children ages birth to 36 months in multiple predominantly-Asian (P-A) and predominantly-Caucasian (P-C) countries. METHODS Parents of 29,287 infants and toddlers (predominantly-Asian countries/regions: China, Hong Kong, India, Indonesia, Korea, Japan, Malaysia, Philippines, Singapore, Taiwan, Thailand, Vietnam; predominantly-Caucasian countries: Australia, Canada, New Zealand, United Kingdom, United States) completed an internet-based expanded version of the Brief Infant Sleep Questionnaire. RESULTS Overall, children from P-A countries had significantly later bedtimes, shorter total sleep times, increased parental perception of sleep problems, and were more likely to both bed-share and room-share than children from P-C countries, p<.001. Bedtimes ranged from 19:27 (New Zealand) to 22:17 (Hong Kong) and total sleep time from 11.6 (Japan) to 13.3 (New Zealand) hours, p<.0001. There were limited differences in daytime sleep. Bed-sharing with parents ranged from 5.8% in New Zealand to 83.2% in Vietnam. There was also a wide range in the percentage of parents who perceived that their child had a sleep problem (11% in Thailand to 76% in China). CONCLUSIONS Overall, children from predominantly-Asian countries had significantly later bedtimes, shorter total sleep times, increased parental perception of sleep problems, and were more likely to room-share than children from predominantly-Caucasian countries/regions. These results indicate substantial differences in sleep patterns in young children across culturally diverse countries/regions. Further studies are needed to understand the basis for and impact of these interesting differences.

SLEEP DISORDERS IN CHILDREN

Many children experience some type of sleep problem. Often, these are transient problems with no long-lasting sequelae. But in certain cases, sleep problems may significantly impact on functioning and well-being. Sleep disorders in children can be classified into two major categories. Dyssomnias include those disorders that result in difficulty either initiating or maintaining sleep or involve excessive sleepiness. Parasomnias are disorders that disrupt sleep after it has been initiated but do not result in complaints of insomnia or excessive sleepiness. Even though sleep disorders in children are common, not enough is known. This article reviews the dyssomnias and parasomnias experienced by children, discusses methodological limitations of the studies reviewed, and presents future directions for research in this field.

Parental Behaviors and Sleep Outcomes in Infants and Toddlers: A Cross-Cultural Comparison

BACKGROUND To assess the prevalence of parental behaviors and other factors of sleep ecology and to analyze their relationships with sleep outcomes in a large sample of children ages birth to 36months in multiple countries/regions. METHODS Parents of 29,287 infants and toddlers (48% boys; Australia, Canada, China, Hong Kong, India, Indonesia, Korea, Japan, Malaysia, New Zealand, Philippines, Singapore, Taiwan, Thailand, United Kingdom, United States, and Vietnam) completed an internet-based expanded version of the Brief Infant Sleep Questionnaire. RESULTS Overall, there is a high level of parental involvement in sleep onset and sleep maintenance for young children, with significant differences in parenting behaviors across cultural groups. For predominantly-Caucasian, the most common behavior occurring at bedtime is falling asleep independently in own crib/bed (57%), compared to just 4% of those children living in predominantly-Asian regions. Parental behaviors and sleep ecology, including parental presence at sleep onset, bedtime, and bedtime routine, significantly explain a portion of the variance in sleep patterns. Overall, parental behaviors are more highly predictive of nighttime sleep outcomes in predominantly-Caucasian regions. Finally, parental involvement in sleep onset mediates the relationship between cosleeping and sleep outcomes. CONCLUSIONS Overall, the best predictors of nighttime sleep are related to parental behaviors at bedtime and during the night. Furthermore, sleep disruption and decreased total sleep associated with bed sharing and room sharing are mediated by parental presence at bedtime. These findings provide additional support for addressing parental behaviors in behavioral interventions for infant and toddler sleep problems.

Prevalence of Diagnosed Sleep Disorders in Pediatric Primary Care Practices

OBJECTIVES: The primary aim was to determine the prevalence of International Classification of Diseases, Ninth Revision (ICD-9), sleep disorders diagnosed by pediatric providers in a large, primary care network. Secondary aims were to examine demographic variables related to these diagnoses and to examine the frequency of prescriptions for medications potentially used to treat sleep disorders. METHODS: Electronic medical records were reviewed for 154957 patients (0–18 years) seen for a well-child visit in 2007. Information collected included ICD-9 sleep diagnoses, demographic variables, comorbid attention-deficit/hyperactivity disorder and autism spectrum disorders, provider type, and medications. RESULTS: Across all ages, 3.7% of youths had an ICD-9 diagnosis for a sleep disorder. The most-common diagnoses were sleep disorder not otherwise specified, enuresis, and sleep-disordered breathing. Predictors of sleep disorders varied according to developmental age group and included growth parameters, comorbid attention-deficit/hyperactivity disorder or autism spectrum disorder, and provider type. Potential sleep-related medications were prescribed for 6.1% of the sample subjects. CONCLUSIONS: This study is one of the first to examine comprehensively ICD-9 sleep diagnoses given by primary care providers in a large representative sample of children 0 to 18 years of age. The 3.7% of patients with ICD-9 sleep diagnoses is significantly lower than prevalence rates reported in epidemiological studies, which suggests that primary care providers may be underdiagnosing sleep disorders in children and adolescents. Because sleep disorders are treatable when recognized, the results from this study suggest a significant need for additional education and support for primary care providers in the diagnosis and treatment of pediatric sleep disorders.

Systematic Review and Meta-Analysis of Behavioral Interventions for Pediatric Insomnia

OBJECTIVE To evaluate and quantify the evidence for behavioral interventions for pediatric insomnia. METHODS Meta-analysis of 16 controlled trials and qualitative analysis of 12 within-subject studies were conducted (total n = 2,560). RESULTS Meta-analysis found significant effects for four specified sleep outcomes: sleep-onset latency, number of night wakings, and duration of night wakings, and sleep efficiency, with small to large effect sizes across the controlled clinical trials involving typical children. No significant effects were found for the two studies conducted with special needs populations. Finally, within-subjects studies demonstrated significant effects for all sleep outcomes with large effect sizes. Risk of bias assessment and GRADE ratings of the quality of the evidence are described. CONCLUSION Moderate-level evidence supports behavioral interventions for pediatric insomnia in young children. However, low evidence for children, adolescents, and those with special needs (due to a lack of studies that met inclusion criteria) highlights the need for future research.

Use of pharmacotherapy for insomnia in child psychiatry practice: A national survey

OBJECTIVE To examine clinical practice patterns regarding non-prescription and prescription medication use for insomnia by child and adolescent psychiatrists. METHODS Survey mailed to 6018 members of the American Academy of Child and Adolescent Psychiatry. RESULTS The final sample (N=1273) reported that insomnia was a major problem in almost a third of their school-aged and adolescent patients and endorsed using medication to treat the insomnia in at least a quarter of these patients. Overall, 96% of respondents recommended at least one of the listed prescription medications in a typical month, and 88% recommended an over-the-counter medication. Alpha agonists were the most commonly prescribed insomnia medication for ADHD (81%), significantly higher than in MR/DD (67%), mood (40%), or anxiety disorders (31%). Trazodone was the most commonly prescribed insomnia medication for children with mood (78%) and anxiety disorders (72%). Antidepressants as a class were also commonly used for children in these diagnostic groups. Atypical antipsychotics, anticonvulsants, and short-acting hypnotics were also more likely to be used in children with mood disorders. Melatonin was recommended by more than one-third of respondents. Mitigation of the effects of sleep disruption on daytime functioning was endorsed as an important rationale for the use of sleep medication; concerns about side effects and the lack of empirical support regarding efficacy were cited as significant barriers to their use. CONCLUSIONS Insomnia is a significant clinical problem in children treated by child psychiatrists for a variety of behavioral, neurodevelopmental, and psychiatric conditions. Management with a broad array of psychotropic medications is common and indicates a highly variable clinical approach to insomnia in this pediatric population.

Behavioral treatment of multiple childhood sleep disorders: Effects on child and family.

Sleep disorders are highlv prevalent among otherwise healthy young children and can be extremelY disruptive to familv life. Treatment was initiated in a multiple baseline fashion for the chronic night waking and nighttime di;t rbance exhibited by a 14-month-old girl. We found that “graduated extinction (gradually increasing the time before attending to the childs crying) resulted in rapid reductions in these sleep disorders. Additionally, data on parental depression and marital satisfaction showed general improvement as a function of improved child sleep patterns. These results are discussed as they relate to the treatment of common childhood behavior disorders and their role in family satisfaction.