Teresa M. Ward

Sleep measurement and monitoring in children with Down syndrome: a review of the literature, 1960-2010.

Children with Down syndrome (DS) are at risk for sleep disturbances due to the anatomical features of the syndrome. Over the past 50 years research studies have measured sleep in children with DS to characterize sleep architecture and its relation to developmental delay. In the 1980s sleep disordered breathing (SDB) was recognized as a major cause of sleep disturbance in DS. The aim of this comprehensive review is to synthesize studies and present the historical context of evolving technologies, methodologies, and knowledge about SDB and DS. Future research opportunities and practice implications are discussed.

Sleep problems in children and adolescents with common medical conditions.

Untreated sleep disturbances and sleep disorders pose significant adverse daytime consequences and place children at considerable risk for poor health outcomes. Sleep disturbances occur at a greater frequency in children with acute and chronic medical conditions compared with otherwise healthy peers. Sleep disturbances in medically ill children can be associated with sleep disorders, comorbid with acute and chronic conditions, or secondary to underlying disease-related mechanisms, treatment regimens, or hospitalization. Clinical management should include a multidisciplinary approach with particular emphasis on routine, regular sleep assessments and prevention of daytime consequences, and promotion of healthy sleep habits and health outcomes.

Nocturnal Sleep and Daytime Nap Behaviors in Relation to Salivary Cortisol Levels and Temperament in Preschool-Age Children Attending Child Care

The purpose of this study was to describe nocturnal sleep and daytime nap duration in relation to salivary cortisol levels and child temperament in nonproblem nappers and problem nappers. Nighttime sleep and nap durations were obtained with continuous actigraph recordings for 3 days and nights (Tuesday, Wednesday, and Thursday) on 38 children aged 3 to 5 years who attended full-day child care centers. Nap times and disruptive behaviors were also observed and coded on each of the 3 days. Parents completed a temperament scale, sleep diaries, and the Childrens Sleep Habits Questionnaire. Salivary cortisol samples were collected midmorning and in the afternoon after a nap on 2 consecutive days (Wednesday and Thursday). Problem napping and disruptive behaviors were associated with more negative affect, higher afternoon cortisol levels, and a smaller decrement in cortisol from morning to afternoon. Problem napping and disruptive behaviors were also associated with longer nighttime sleep, shorter nap durations, and later rise times. These data provide some insight into the associations among nighttime sleep, napping behavior, and salivary cortisol.

A review of pain measures for hospitalized children with cognitive impairment

PURPOSE The aims of this review were to examine pain measures for hospitalized children with cognitive impairment who are unable to self-report and to describe the best available evidence for their clinical utility in acute care settings. DESIGN AND METHODS Electronic searches to identify published evidence were conducted and studies reviewed. Reported psychometrics and feasibility of the Non-Communicating Childs Pain Checklist-Postoperative Version, Individualized Numeric Rating scale, Pediatric Pain Profile, and revised Face, Leg, Activity, Cry, and Consolability scale were examined. CONCLUSIONS These four measures have established validity and reliability. However, clinical utility findings varied. PRACTICE IMPLICATIONS The revised Face, Leg, Activity, Cry, and Consolability scale has demonstrated feasibility in acute care settings related to ease of use, time requirements, and flexibility regarding caregiver input.

Disease activity and fatigue in juvenile idiopathic arthritis

To examine the association between parent/proxy‐ and child‐reported fatigue and disease activity in children with polyarticular, extended oligoarticular, and persistent oligoarticular juvenile idiopathic arthritis (JIA).

Nighttime sleep and daytime nap patterns in school age children with and without asthma

Objective: This research examines subjective and objective report of naps and nighttime sleep in 9- to 11-year-old children with and without asthma. Methods: This between subjects study collected prospective self-report diary and objective actigraphy measures of sleep from 27 children with and 27 without asthma during a 7-day/6-night at-home monitoring period. Results: Thirty-two percent of participants reported daytime naps. Nappers were more likely to be children with asthma (12/27 vs. 5/27, p = 0.04) even though the children with asthma did not report being more tired, sleepy, or less alert in the morning. Nappers did not differ from non-nappers on self-report measures of overall sleep quality or number of awakenings but were documented, via objective measures, to have later (clock time: 23:05 vs. 22:21, p = 0.04) and more variable (Levine’s Test for Equality of Variances: F = 10.68, p = 0.002) sleep onset times than non-nappers. Sleep offset times did not differ between the nappers vs. non-nappers, therefore, nappers had fewer total minutes of nighttime sleep than did the non-nappers (437 vs. 465, p = 0.04). Later (clock time: 23:01 vs. 22:15, p = 0.01) sleep onset times were also documented in minority vs. Caucasian children. Conclusions: Napping appears a more common behavior than expected especially in children with asthma or of minority ethnicity but the reasons are unclear. Self-report measures may not capture important sleep characteristics that objective measures can identify. Strategies to reduce late and variable bedtimes of all children are needed given our awareness of the negative cognitive, emotional, and behavioral consequences of poor sleep in children.

Daytime Physical Activity Levels in School-Age Children With and Without Asthma

Background:Physical activity (PA) is a significant predictor of health outcomes in children with and without chronic conditions. Few researchers have used actigraphy as an objective measure of PA during the child’s normal daily routines, and the findings have been inconsistent. It is unclear if asthma can contribute to low PA levels. Objectives:The aim of this study was to compare daytime PA levels in children with and without asthma and examine the relationships among asthma, PA, body mass index (BMI), and child reports of symptoms. Methods:Physical activity as measured by actigraphy and self-report symptoms of coughing, wheezing, chest tightness, perceived tiredness, sleepiness, and alertness were obtained in 54 children aged 9–11 years with and without asthma for 7 consecutive days. Activity variables derived from actigraphy included (a) mean daytime activity level; (b) peak daytime activity level; and (c) time duration spent in sedentary, light, moderate, vigorous, and total moderate plus vigorous PA (MVPA). Results:Children with and without asthma did not differ on BMI or activity levels. Children with asthma reported more activity limitations due to breathing problems than children without asthma (p < .01). In multivariate analyses, asthma predicted reduced mean, peak, and total time spent in MVPA level after controlling for gender, BMI, and self-report of symptoms. A significant interaction was found between asthma and BMI on mean, peak, and total time spent in MVPA. Discussion:The association between asthma and PA is complex when the child’s BMI is considered. Results suggest that reduced PAs with respect to respiratory symptom severity, childhood obesity, and functional impairment are important areas for future studies.

Parent-Child Agreement in Report of Nighttime Respiratory Symptoms and Sleep Disruptions and Quality

INTRODUCTION Asthma control requires assessment of nighttime symptoms and sleep disruption. Cognitive and emotional development enables most school-aged children to report nocturnal problems, but providers often rely only on parental report, potentially limiting the comprehensiveness of their assessments and their ability to support the childs emerging efforts at shared management of their illness. This study investigated parent-child concordance in report of nighttime respiratory symptoms, sleep disruption, and quality of sleep in a sample of 9- to 11-year-old children with asthma. Secondarily, similar concordance patterns in an equal number of dyads where the child was asthma free were examined to illustrate the potential influence of asthma. METHOD Parents and children completed 1-week diaries in their homes without confiding in one another. The probability of knowing the childs report on a specific item if the parents report was known was assessed using contingency tables. RESULTS Within the asthma group, parent-child reports differed significantly across all symptoms and sleep parameters. Parents most often reported fewer symptoms and awakenings and better quality of sleep than did their child. Concordance rates were lowest for morning perceptions of tiredness, sleepiness, and alertness in both asthma and non-asthma groups. DISCUSSION Both parents and school-aged children with asthma need to be asked about nighttime asthma symptoms, sleep, and morning perceptions when attempting to evaluate asthma control. Assessment of sleep in all children should include parent and child reports and would benefit by the addition of objective measures.

Polysomnography and Actigraphy Concordance in Juvenile Idiopathic Arthritis, Asthma and Healthy Children

The aims of this study were to evaluate sensitivity, specificity and accuracy with an epoch‐by‐epoch comparison of polysomnography (PSG) and actigraphy with activity counts scored at low, medium and high thresholds, and to compare PSG‐derived total sleep time (TST), sleep efficiency (SE) and wake after sleep onset (WASO) to the same variables derived from actigraphy at low, medium and high thresholds in 9‐ to 11‐year‐old children with juvenile idiopathic arthritis (JIA), asthma and healthy control children. One night of PSG and actigraphy were recorded. Pairwise group comparisons for sensitivity showed significant differences at the low [Tukey’s honest significant difference (HSD) P < 0.002], medium (P < 0.001) and high thresholds (P < 0.001) between JIA and asthma groups, and at the high threshold between JIA and controls (P < 0.009). Significant differences were found for specificity at the low (P < 0.001), medium (P < 0.001) and high thresholds (P < 0.001) between JIA and asthma groups, and between JIA and controls (low, P < 0.002: medium, P < 0.002: high, P < 0.008 threshold). PSG TST, WASO and SE were not significantly different among the groups, but significant group differences were found for actigraphy TST, WASO and SE at all three thresholds. Actigraphy showed the least overestimation or underestimation of sleep or wakefulness at the medium threshold for TST and WASO for all three groups. Compared to PSG, actigraphy was most accurate in the identification of sleep from wakefulness in 9‐ to 11‐year‐old healthy children, and less accurate in children with JIA and asthma.

From Personal Informatics to Family Informatics: Understanding Family Practices around Health Monitoring

In families composed of parents and children, the health of parents and children is often interrelated: the health of children can have an impact on the health of parents, and vice versa. However, the design of health tracking technologies typically focuses on individual self-tracking and self-management, not yet addressing family health in a unified way. To examine opportunities for family-centered health informatics, we interviewed 14 typically healthy families, interviewed 10 families with a child with a chronic condition, and conducted three participatory design sessions with children aged 7 to 11. Although we identified similarities between family-centered tracking and personal self-tracking, we also found families want to: (1) identify ripple effects between family members; (2) consider both caregivers and children as trackers to support distributing the burdens of tracking across family members; and (3) identify and pursue health guidelines that consider the state of their family (e.g., specific health guidelines for families that include a child with a chronic condition). We contribute to expanding the design lens from self-tracking to family-centered health tracking.