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

ObjectiveTo 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 methodsA 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).ResultsAcross 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.ConclusionsOverall, 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.     

Sleep location and parent-perceived sleep outcomes in older infants

ObjectivesInitial studies indicate more independent and consolidated sleep in the first few months in infants who sleep separately. Little is known, however, about the relationship of sleep location (separate room, room-sharing, bed-sharing) with sleep outcomes in older infants (ages 6–12 months). It was expected that those who sleep in a separate room would have better parent-perceived sleep outcomes and more positive sleep health behaviors.MethodsParents of 6236 infants (6–12 months) in the United States (US) and 3798 in an international sample (Australia, Brazil, Canada, Great Britain, and New Zealand) completed a smartphone app-based expanded version of the validated Brief Infant Sleep Questionnaire.ResultsA total of 37.2% of the infants in the US and 48.4% in the international sample slept in a separate room. In both samples, infants who slept in a separate room as opposed to room-sharing or bed-sharing had parent-perceived sleep outcomes and sleep-related behaviors that reflected earlier bedtimes, shorter time to fall asleep, more nighttime and total sleep, and increased sleep consolidation. They were also more likely to have a consistent bedtime routine and to fall asleep independently, as well as less likely to feed to sleep at bedtime and during the night. In addition, parents of separate room sleepers perceived bedtime to be less difficult and sleep to be better overall.ConclusionsOverall, 6- to 12-month-old infants who slept in a separate room had better reported sleep outcomes and fewer parent-perceived disturbances at bedtime than infants who room-shared with their parents, as well compared to those who slept in their parents' bed.     

Parent knowledge of child sleep: a pilot study in a children's hospital cohort

Objectives/BackgroundParent knowledge about child sleep may influence parent efforts to support healthy sleep in their children. The present study aimed to describe parent knowledge of child sleep in a hospital cohort and potential correlates including barriers to children's bedtime, information seeking about child sleep, and demographics such as child age, parent education, and household income.MethodsIn total, 115 parents of children aged 2–12 years attending hospital inpatient wards or day ward were approached individually and invited to complete the questionnaire. Questionnaire items were modified measures in published articles, identified through literature review, or developed from clinical experience.ResultsParents on average answered half of the knowledge questions accurately, and knowledge about child sleep was positively correlated with education and household income. Parents who sought information from books or the Internet had greater knowledge about child sleep than parents who did not endorse these sources of information. The accuracy of parent estimations of their child's sleep requirements varied: 55% were within recommendations, while 26% underestimated their child's sleep requirements, 19% overestimated. Parents who correctly estimated their child's sleep requirements had higher education and income on average and were more likely to parent younger children (age 2–5 years). Parents who overestimated or underestimated sleep requirements were more likely to identify greater barriers to their child's bedtime.ConclusionOverall knowledge of child sleep in this sample was poor, consistent with samples from North American communities. Future studies should examine whether knowledge about child sleep and barriers to children's bedtimes are related to actual child sleep behaviors or parent practices to support their children to achieve a healthy sleep.     

Time for bed! Earlier sleep onset is associated with longer nighttime sleep duration during infancy

Objective/backgroundClinical recommendations include putting infants to bed using a consistent bedtime routine at an appropriate hour to promote longer nighttime sleep. Actigraphy was used in this exploratory study to examine how bedtime routines and nighttime sleep onset were associated with nighttime total sleep time (TST) and efficiency from 6 to 24 weeks of age.Patients/methodsInfants (n = 24) wore sleep actigraphs for three, one-week periods at 6, 15, and 24 weeks of age. Nighttime TST, sleep efficiency, sleep onset and offset were quantified. Mothers reported on infant bedtime routines using the Brief Infant Sleep Questionnaire at each age. Multilevel models examined between- and within-person associations.ResultsAs infants aged, sleep onset was earlier, and bedtime routines became shorter (p's < 0.05). Infants fell asleep between 7 and 8:00PM on 24% of the nights. Most mothers (70%) reported that they often fed infants to sleep for the night. For every 1 h earlier in infants' usual sleep onset, nighttime TST was 34.4 min longer that night (p < 0.01). Infants with earlier than usual sleep onset had slightly earlier sleep offset the next morning (8.4 min for every 1 h earlier in onset; p = 0.02). Between-person analyses showed similar patterns. Infants with a more consistent bedtime routine and who were not typically fed to sleep at bedtime had longer nighttime TST at 6 weeks, with a trend or no association at later ages.ConclusionInfants who fell asleep earlier also slept longer at night. Keeping infants up later in hopes of them sleeping in longer may be counterproductive.     

Night waking in Thai infants at 3 months of age: association between parental practices and infant sleep

BACKGROUND AND PURPOSE: Night waking is common among infants and can create sleep deficit in both parents and infants. Sleep practices are influenced by cultural variations which may affect the prevalence and associated factors of frequent night waking. Our objective was to determine whether differences in parental practices related to infant sleep are associated with frequent night waking in Thai infants. METHODS: A cross-sectional survey based on interviews with parents of infants aged three months, birth weight greater than 2500 g, conducted under the Prospective Cohort study of Thai Children (PCTC). RESULTS: Of the total sample, 82.9% (3172 of 3826) of parents provided completed night waking information. The mean number (+/-standard deviation [SD]) of awakenings per night was 2.7+/-1.1, 47.3% awoke 1-2 times per night, and 46.9% awoke 3-4 times per night. The group of frequent night wakers (more than 14 night wakings per week, n=1634) was compared with the group of infrequent night wakers (n=1538). Significant and independent associations were present between frequent night waking and male gender (odds ratio [OR] of 1.5; 95% confidence interval [CI], 1.3-1.8), more than three naps per day (OR, 1.3; CI, 1.1-1.5), use of a swinging or rocking cradle (OR, 1.5; CI, 1.2-1.98), falling asleep while feeding (OR, 1.3; CI, 1.1-1.5), and breastfeeding only (OR, 1.2; CI, 1.1-1.4). No significant association was noted between frequent night waking and parental age, education, occupation, household income, type of parental response to infant's nighttime crying, or type of diaper. CONCLUSION: An association with frequent night waking was demonstrated with various factors of parental practice related to infant sleep, such as number of naps, use of a swinging or rocking cradle, breastfeeding only, and falling asleep while feeding. Further documentation of these associations may be clinically important. Implementing preventive interventions may be able to reduce frequent night waking in early infancy.     

Bedtime diazepam enhances well-being in children with spastic cerebral palsy

In work with children with cerebral palsy at Ashirvad, Child Development and Research Centre, Chennai, India, the authors were confronted with fretful children who resisted any attempt to mobilize their limbs due to hypertonia and muscle spasm. It was found that administering a bedtime dose of diazepam to reduce hypertonia and muscle spasm alongside passive stretching exercises significantly improved the behaviour of the child. There was significant improvement in the well-being of the child during the activities of daily living and this reduced the family's burden of caring for the child. In this double blind, placebo-controlled, randomized clinical trial, each child received a bedtime dose of diazepam or placebo. The bedtime diazepam relaxed the muscles and this made the passive stretching easy and the movements sustained the muscle relaxation during the day. There were fewer unwarranted crying spells during the day and less wakefulness during the night. The adverse effect of day time sedation was not observed with the use of a single dose of diazepam at bedtime.     

Seizures of sleep onset: clinical and therapeutical aspects.

We studied the clinical characteristics and therapeutic response of 10 patients who presented with seizures shortly after falling asleep as the only or main manifestation of their epilepsy. The clinical evaluation was designed to investigate the appearance of seizures during diurnal and nocturnal sleep. The pharmacological response to coffee or amphetamine was investigated after normalization of previous anticonvulsant treatment. Seven of 10 patients (70%) presented with seizures during the siesta, and in 3 of 10, seizures occurred if they fell asleep at any time of the day. Seizures were detected in later hours of the night in five patients as sleep reinitiation seizures or seizures without previous awakening. The response to anticonvulsants alone was disappointing. The addition of coffee or amphetamine suppressed seizures of sleep beginning at night or during the siesta. Neither of them had an influence on sleep diurnal seizures outside of the siesta or on seizures of nocturnal sleep reinitiation. Suppression of coffee or amphetamine was followed by reappearance of the seizures.     

Dilemmas, diagnosis and de-stigmatization: parental perspectives on the diagnosis of autism spectrum disorders

Many children who display autistic behaviours at clinical levels do not receive a formal diagnosis. This study used qualitative methods to examine parental influence in pursuing or avoiding a diagnosis of autism spectrum disorder (ASD). The aim was to explore the function of ASD diagnosis for parents, and examine whether a diagnosis affected how parents perceived ASD. Seventeen parents participated in in-depth semi-structured interviews, which were analyzed using thematic and grounded theory approaches. Data analysis revealed dilemmas faced by parents: whether to act to retain the 'normal' status of the child or to 'normalize' the child through diagnosis and subsequent remediation. Parents who had received an ASD diagnosis for their children became proactive in trying to reduce stigmatization of ASD more widely, and in some cases actively advocating ASD diagnosis to other parents. Thus their actions may make it more likely that others will opt for diagnosis in the future.     

Sleep patterns,problems, and ecology in young children born preterm and full-term and their mothers

BackgroundPrevious studies of sleep patterns and problems in preterm infants compared to full-term infants have yielded mixed results, with little known about sleep ecology. The aims of this study were to compare sleep patterns, sleep problems, and sleep ecology across developmental stages (birth to 36 months) in preterm (3 or more weeks early) infants and toddlers to those born full-term, in addition to their mothers’ sleep.MethodsMothers of 834 young children in Brazil (ages 0–35.9 months), half preterm and half full-term (matched for sex and chronological age), completed the Brief Infant Sleep Questionnaire and the Pittsburgh Sleep Quality Index.ResultsAcross the entire sample, preterm and full-term infants were similar for most sleep parameters, including sleep onset latency, number and duration of night awakenings, and sleep duration, as well as sleep ecology parameters, including falling asleep independently and sleep location. However, preterm infants were more likely to be held to initiate sleep, given a bottle to resume sleep after waking, and less likely to be breastfed to resume sleep after waking. Mothers of preterm infants, however, were more likely to report a parent-perceived sleep problem, although maternal-perceived confidence in managing child sleep and bedtime difficulty were similar. Finally, maternal sleep parameters were similar between groups.ConclusionsOverall, these results indicate that sleep patterns, sleep problems, and sleep ecology among preterm infants and toddlers and their mothers are largely similar to those of full-term infants and toddlers and their mothers, even within the first few months.     

Massage-based bedtime routine: impact on sleep and mood in infants and mothers

Establishment of a consistent bedtime routine is often recommended to families with young children with sleep difficulties. However, there are limited studies assessing specific bedtime routines in the treatment of infant and toddler sleep disturbances. Thus, the purpose of this study was to examine the impact of a massage-based bedtime routine on infant sleep, maternal sleep, and maternal mood. A total of 123 mothers and their 3- to 18-month-old infant were randomly assigned to a routine (one-week baseline of usual bedtime routine, two-weeks intervention) or control group (three-weeks of their usual bedtime routine). All mothers completed the Brief Infant Sleep Questionnaire (BISQ) on a weekly basis and measures of maternal sleep and mood (eg, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Edinburgh Postnatal Depression Scale). This bedtime routine resulted in improvements in child and mother night wakings, maternal perceptions of child sleep and mood (ie, sleep problem, bedtime ease, and morning mood), and improvements in maternal sleep quality. No comparative changes were seen in the control group. Notably, other than number of night wakings for both the child and the mother, there were no changes in other sleep patterns including sleep onset latency, duration of night wakings, longest stretch of sleep, or sleep duration. This study supports recommending a massage-based routine in those families, with the codicil that improvements in maternal perceptions and maternal sleep will be noted, with few improvements in sleep itself other than night wakings.     

Social competence and emotional/behavioural problems in children of psychiatric inpatients

The social competence and emotional/behavioural problems among 80 5–16-year-old children of 46 inpatients with various psychiatric disorders were assessed by the parents using a Swedish version of the Child Behavior Checklist (CBCL). The ratings of these children were compared to a normative sample of school children, but also whether type of psychiatric disorder among the parents was related to psychosocial functioning in their children. Fifty percent of the parents had a psychotic disorder; other common diagnoses were depressive, neurosis or personality disorders. Overall, children of psychiatric inpatients were perceived by the parents to be less socially competent and to have more emotional/behavioural problems than school children in the same age groups. However, 25% of the children of psychiatric parents were rated as having more severe problems (corresponding to the 90th percentile of the normative sample). About 15% of the children had total problem levels comparable to child psychiatric samples, but only 5% did actually receive ongoing help from the child psychiatric service. Parents with a depressive disorder or a crisis reaction also regarded their children to be more anxious/depressed, and to have more social problems than those of parents with other psychiatric disorders. Four CBCL items were found to be strong predictors of being a child of a psychiatric parent or parent in the normative sample. We suggest that the CBCL might be a valuable clinical tool in the screening and identification of those children of psychiatrically ill parents, who show more extreme problem scores and therefore might need help because of psychological problems. Accepted: 11 November 1999     

The role of coping in maintaining the psychological well-being of mothers of adults with intellectual disability and mental illness

BACKGROUND: Mothers who have a child with intellectual disability (ID) or mental illness face a lifetime of caregiving responsibilities and challenges. The present study investigated changes over time in how mothers cope with the challenges of caring for an adult child with disabilities and the effects of changes in coping on maternal well-being. METHODS: A sample of 246 ageing mothers of adults with ID and 74 mothers of adults with mental illness was drawn from two parallel longitudinal studies of later-life caregiving. RESULTS: There was considerable variability at the individual level in the degree to which mothers changed over time in their use of problem-focused and emotion-focused coping strategies. For both groups, an increase in their use of emotion-focused coping led to declining levels of well-being. For the parents of adults with ID, an increase in their use of problem-focused coping resulted in a reduction in distress and an improvement in the quality of the relationship with their adult child. For the parents of adults with mental illness, an increase in the use of problem-focused coping had no effect on levels of distress, but led to an improved relationship with their adult child. CONCLUSIONS: The present study underscores the importance of coping in the lives of older mothers of adults with disabilities.     

Sleep and behavioral/emotional problems in children: a population-based study

BackgroundThe potential relationships between sleep–wake behaviors and emotional/disruptive problems in otherwise healthy school-aged children are unclear.MethodsA parental questionnaire was developed for the epidemiologic survey of children’s sleep and wake behavioral patterns. The questions covered a wide range of features including sleep length (school days, weekends), time to fall asleep, night awakenings, bedtime and nighttime sleep-related behaviors, daytime sleepiness, irritability, and tiredness. To assess psychiatric symptomatology, the Rutter Scale B2 was completed by teachers. In addition to the total score, sub-scores of emotional, hyperactivity, and conduct problems were obtained. The representative population sample comprised 779 children (403 girls), with an age range of 6–11 years.ResultsHyperactivity and conduct problems at school in boys were both associated with parental reports of bedtime resistance. Hyperactivity was also associated with longer sleep duration during weekends. Conduct and emotional problems in girls were associated with earlier bedtime during school days. Emotional problems in girls were also associated with longer sleep durations in school days and weekends.ConclusionBedtime resistance was the only sleep behavior associated with either hyperactivity or conduct problems in children, and longer sleep durations appear to occur more frequently in children with both hyperactive or emotional problems. Information about good sleep hygiene at bedtime may help parents setting sleep limits.     

Buspirone: sedative or stimulant effect?

OBJECTIVE: The primary objectives of this study were to evaluate the effects of initial and continued administration of buspirone on sleep induction and maintenance and sleep stage parameters, to determine the presence or absence of any drug-induced side effects, and to ascertain the presence or absence of sleep disturbances following abrupt withdrawal of the drug. METHOD: Six insomniac subjects who had chronic complaints of difficulty falling asleep and/or staying asleep and who were in good physical health, were not suffering from any major mental disorders, and had not used any medication for at least the last month participated in a 16-night sleep laboratory protocol. The protocol consisted of 4 placebo-baseline nights, 7 nights on which buspirone, 10 mg at bedtime, was administered, and 5 placebo-withdrawal nights. RESULTS: Wake time after sleep onset increased moderately during the first 3 nights of drug administration (there was a marked and significant increase on the first night) and increased by lesser degrees with continued drug administration. Overall, reports of side effects were infrequent. Following drug termination, there was a delayed and mild increase in sleep difficulty above baseline. CONCLUSIONS: These data not only confirm that buspirone lacks sedative effects but also suggest that the drug may have stimulant properties. Further, these findings suggest that buspirone has limited usefulness in anxious patients with concomitant sleep difficulties.     

The relationship between loss of parents in the holocaust, intrusive memories, and distress among child survivors

The prevalence of intrusive memories of the Holocaust and their relationship to distress was examined among 272 child survivors in Israel. Using attachment theory as a conceptual framework, the authors also examined the effects of type of experience and loss of parents in the Holocaust, psychological resources, other life events, and sociodemographic characteristics on distress and symptomatic behavior. Eighty five percent of the participants reported suffering from intrusive memories. Structural equation modeling showed that survivors who lost one or both parents in the Holocaust suffered more distress because of more intrusive memories. These findings suggest that intrusive memories may be part of unfinished mourning processes related to the loss of parents in the Holocaust.     

Child Characteristics Influencing Referral to Mental Health Services

This study explored whether certain child characteristics (age, type of problem presented, and gender) influenced the referral decisions of parents, general practitioners, and child psychologists. These three groups were taken as key gatekeepers in controlling access to mental health services. Results suggested that age of child and type of problem significantly affected the subject's responses whilst sex of child did not. Psychologically disturbed 10-year olds may be more likely to reach mental health services than psychologically disturbed 3-year olds, and children who showed their disturbance in terms of conduct disorder may be more likely to arouse concern than those who present with emotional disturbance.     

Human tryptamine metabolism decreases during night sleep

Fourteen healthy male volunteers took part in a study which aimed to determine whether utilization of tryptamine changes in relation to sleep and wakefulness. For this purpose urine samples were collected every 4 hr and urinary tryptamine and indoleacetic acid (IAA) were determined by fluorometric and spectrophotometric methods. Urinary concentration of IAA progressively increased during the day and fell during the night when subjects were asleep but not when subjects were awake. This evidence indicates that behavioral state rather than circadian variation determines the level of urinary IAA. Tryptamine (T) concentration also progressively increased during the day and continued to increase during the night. The mean log10 (IAA/T) ratio indicates that tryptamine metabolism decreases during the night when subjects are asleep. Therefore, human sleep may be associated with diminished activity of peripheral tryptamine.     

Sleep disorders of early childhood: a review

Night awakening and refusal to go to sleep are common problems during the first three years of life, comprising 6-30% of children in the general population. The organization and regulation of child sleep is thought to be closely related to his mode of attachment to his mother. Sleep aids (pacifier, teddy bear, etc.) during the night seem to reduce the occurrence of sleep disorders whereas prolonged breastfeeding and co-sleep with the parents interfere with the normal development of sleep. During the preschool years, the main issue affecting sleep is the ability of parents to set firm limits while respecting the sense of autonomy of the child. Sleep disorders are considered to be more common among physically and mentally handicapped children. Children with a difficult temperament sleep less than those with an easy one. A clear association is found between sleep patterns and psychopathology of the mother probably due to emotional unavailability and inappropriate behavior. Evaluation of the disorder should follow medical examination. It should take place in the presence of the child in order to view the real interaction as well as given information about the reported interaction between the child and his mother. Therapeutic interventions in cases of early childhood sleep disorders can be behavioral or psychodynamic and are advised to be focused and brief, unless there is psychopathology in the parents.     

Sleep habits in infants: the role of maternal education

ObjectiveSleep disturbances are frequent in infants. Early development of sleep routines has a positive effect on sleep quality. The objective of this study was to assess the impact of maternal education on the development of infants’ sleep habits (SHs).MethodsThis was an experimental, longitudinal study. Postnatal mothers were allocated into two groups: to receive (intervention group, IG), or not receive (control group, CG) information on sleep hygiene. Individual 15-min sessions were provided and a leaflet was handed to the IG. A questionnaire on infants’ SHs was applied by telephone/e-mail at 1, 2, 4, and 6 months of age.ResultsAt least three questionnaires were answered by 314 mothers. Results were adjusted for maternal age, education, and race. In the IG, infants acquired more independent sleep habits, an effect still present at six months; slept more frequently in their own beds; adjusted odds ratio (OR_adj) 3.8, 95% confidence interval (CI) (1.1–13.5); fell asleep more frequently alone (OR_adj, 4.29; 95% CI, 2.4–7.6); fell asleep more frequently in their own beds (OR_adj, 6.1; 95% CI, 3.5–10.6) and needed less breast/bottle feeding to fall asleep (OR_adj, 2.68; 95% CI, 1.5–4.6). The autonomy was greater in IG infants after night awakenings; also until six months they went back to sleep more frequently alone (OR_adj, 3.88; 95% CI, 2–7.5) and needed less breast/bottle feeding (OR_adj, 2.35; 95% CI, 1.3–4.3). No differences were found regarding the need for light, television or other routines to fall asleep or after night awakenings.ConclusionMaternal education is positively associated with the adoption of autonomous SHs in infants. Early maternal education is an adequate prevention strategy to be considered in neonatal care.     

Parent-reported sleep problems in school-aged children with fetal alcohol spectrum disorder: association with child behaviour,caregiver, and family functioning

Objective/backgroundSleep problems are a common clinically reported area of concern for children and adolescents with fetal alcohol spectrum disorder (FASD). However, limited empirical research has been undertaken investigating sleep problems for children with FASD. The current study aimed to examine the associations between parent-reported sleep problems in children with FASD and child behaviour, caregiver mental health and health-related quality of life and family functioning.Participants163 caregivers of children diagnosed with FASD aged 5–17 years were included in the current study.MethodCross-sectional online survey that collected information pertaining to child sleep problems (difficulty falling asleep, difficulty staying asleep and/or frequent waking during the night and waking early in the morning) and standardised caregiver reported measures of child behaviour, caregiver mental wellbeing, caregiver health-related quality of life, and family functioning.ResultsSleep problems were common, affecting 65.6% (n = 107) of participants. Difficulty falling asleep (56.4%) was the most common sleep problem encountered, followed by difficulty staying asleep (44.8%) and waking early (29.4%). Sleep problems were associated with increased rates of child behaviour problems and caregiver anxiety and negative impacts on caregiver and family quality of life.ConclusionSleep problems in children and adolescents with FASD are common and associated with poorer child, caregiver and family outcomes. Future research needs to determine whether effective identification and management of sleep problems can reduce adverse outcomes.