Feasibility of using actigraphy and motivational-based interviewing to improve sleep among school-age children and their parents.

Inadequate sleep occurs in 25% of our nation's children; poor sleep is associated with physical, cognitive, and social consequences. Developing good sleep hygiene in middle childhood is important, because habits typically extend to adolescence and adulthood; yet, there has been little research on sleep interventions for school-age children. The purpose of this study was to determine the feasibility of a developmentally tailored, motivation-based intervention (MBI) focused on improving sleep behaviors in school-age children aged 8-11. Nine parent-child dyads participated in an 8-week protocol utilizing MBI and comparisons of objective (actigraphy) and subjective (sleep diaries) data. Results suggest that parent and children are able to identify a target behavior to change and complete the protocol. Further, preliminary evidence indicates that sleep patterns change using MBI. Future research will be directed toward comparative effectiveness testing and exploring ways in which it can be adapted and incorporated into school nursing practice.

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.

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.

Light is beneficial for infant circadian entrainment: an actigraphic study.

AIM: This article is a report of an exploratory study of the relation between light exposure and circadian rest-activity patterns in infants. BACKGROUND: Ambient light is a major environmental stimulus for regulation of circadian rhythm of sleep and wake in adults, but few studies have been conducted to examine environmental light exposure in relation to rest-activity circadian rhythm parameters of infants. METHODS: An intensive within-subject design was used with a convenience sample of 22 infants (mean postnatal age 49·8 days) who wore a combined light and activity monitoring device for seven consecutive days at home. For each infant, light data (lux) were aggregated over the 7 days into categories of illumination and expressed in mean minutes/day. Circadian light and activity parameters, including mesor, amplitude, acrophase and R(2) cosinor fit, were determined using cosinor analysis. Associations between light exposure and circadian rest-activity rhythm parameters were examined using correlation and regression analyses. Data were collected between 2006 and 2007. RESULTS: Infants spent only one-eighth of their daytime hours in an environment with >100 lux light level. There was a relatively large statistically significant relation between the acrophase of light exposure and the acrophase of activity. Increased duration of daily exposure to >100 lux of illumination, and increased amplitude of circadian rhythm of light were associated with stronger circadian patterns of infant activity. CONCLUSION: Results suggest an association between light and activity patterns and that increasing duration of exposure to moderate light levels may be a simple and economical nursing intervention during the early postnatal weeks.

Sleep disturbances and neurobehavioral functioning in children with and without juvenile idiopathic arthritis.

OBJECTIVE: To compare sleep disturbances and neurobehavioral function in children with juvenile idiopathic arthritis (JIA) to age- and sex-matched control children. METHODS: Children (n = 116) ages 6-11 years with (n = 70) and without (n = 46) JIA and their parents participated. Parents completed questionnaires on sleep habits, sleep behavior, and school competence of their children; children completed computerized neurobehavioral performance tests. RESULTS: Compared to control children, children with JIA had a statistically significant (P < 0.001) greater mean overall sleep disturbance score and higher scores on 6 of 8 subscales (all P < 0.03) of the Children's Sleep Habits Questionnaire (CSHQ). There were no group differences on neurobehavioral performance test scores. However, regardless of group, children with an overall CSHQ score above an established cutoff for clinically significant sleep disturbances had slower mean simple reaction time (t = -2.2, P < 0.03) and mean 5-choice reaction time (t = -2.3, P < 0.02) compared to those below the cutoff score. The CHSQ overall sleep disturbance score predicted reaction time (P < 0.009) after controlling for age, intelligence quotient, medication, and group. CONCLUSION: Children with JIA have more parent-reported sleep disturbances, but performed as well as control children on a series of standardized computer tests of neurobehavioral performance. Children with more disturbed sleep had slower reaction times.

Mother-infant activity synchrony as a correlate of the emergence of circadian rhythm.

OBJECTIVE: Entrainment to the day-night cycle is critical for infant sleep and social development. Synchronization of infant circadian systems with the social 24-hr day may require maternal activity signals as an entraining cue. This descriptive and exploratory research examines the activity level and circadian pattern in mothers and infants. METHOD: Twenty-two healthy mothers and their infants (postnatal age 49.8 ± 17.1 days) wore actigraph monitors for seven days. Daytime (06:00-21:59) and nighttime (22:00-05:59) activity levels and circadian parameters of rest-activity patterns (i.e., mesor, amplitude, acrophase, and 24-hr cosinor fit) were calculated. RESULTS: Mothers and infants were significantly more active during the day than at night. The goodness-of-fit index for the model (R2) indicates that circadian rhythm accounted for a mean of 29 ± 10% and 12 ± 8% of the variability in maternal and infant activity, respectively. Acrophase of activity occurred at 15:46 ± 1:07 for the mothers and 15:20 ± 1:21 for the infants. The mean within-dyad correlation of activity counts was r = .46 ± .11, and the within-dyad correlation was associated with the amplitude (r = .66, p < .01) and 24-hr cosinor fit of infant activity (r = .67, p < .01). CONCLUSIONS: Our findings suggest maternal rhythms as a possible exogenous influence on shaping an infant's emerging rhythms and synchronizing them with the external light-dark cycle. Strong pattern synchrony between maternal and infant activity may support infant circadian entrainment and enhance a regular 24-hr sleep-wake schedule during the early postnatal weeks.

Sleep disturbance, daytime sleepiness, and neurocognitive performance in children with juvenile idiopathic arthritis.

STUDY OBJECTIVES: To compare daytime sleepiness and neurobehavioral performance in children with active and inactive juvenile idiopathic arthritis (JIA), and explore relations among measures of sleep disturbance, daytime sleepiness, and neurobehavioral performance. DESIGN: Cross-sectional, comparison. SETTING: A university-based research sleep laboratory. PARTICIPANTS: Seventy (70) children 6-11 years of age with active or inactive JIA. MEASUREMENTS AND RESULTS: Self-reported daytime sleepiness, multiple sleep latency tests (MSLTs), and computerized neurobehavioral performance test scores were obtained after 2 nights of polysomnography. Children with active disease (mean physician global rating score = 2.9 +/- 1.9 SD) showed shorter mean MSLT latency (15 +/- 6.0 min) than those with inactive disease (16.5 +/- 5.5 min, P < 0.03). Scores on neurobehavioral performance tests showed no group differences. However, number of wake bouts predicted sustained visual attention (rapid visual processing, P < 0.05) and apnea hypopnea index (AHI) predicted reaction time (P < 0.0001), after controlling for age, IQ, medication, and disease status. CONCLUSION: Indices of sleep disturbance were associated with validated tests of neurobehavioral performance in JIA, regardless of disease activity. Additional research is needed about the extent of sleep disturbances in relation to neurocognitive performance in JIA and compared to healthy children.

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 child's 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 child's report on a specific item if the parent's 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.

An Internet-based migraine headache diary: issues in Internet-based research.

OBJECTIVE: The primary purpose of this study was to explore the feasibility and acceptability of using an Internet-based headache diary to obtain acceptable completion rates of daily diaries. BACKGROUND: Migraine sufferers often perceive that headaches are unpredictable, but 70% have prodromal warning symptoms that may be identified via daily headache diaries. Although diaries are widely used for tracking headaches, Internet-based diaries have not been used previously. METHODS: A conventional headache diary was formatted for the Internet to collect daily headache data over 4 months using a time-series design.Women between 18 and 55 years who were not pregnant or postmenopausal, and whose headaches met migraine criteria, were recruited primarily via the Internet, completed online consent forms, and were screened via telephone. They completed health history questionnaires and daily diary pages containing scales and open-ended questions,which were saved to a database. Diaries were reviewed and participants were contacted weekly. Completion dates were tracked electronically. Follow-up interviews addressed perceptions about study experiences, and participants received feedback about headache patterns. RESULTS: The majority of participants were recruited from discussion boards and free classified web sites. Of the 101 participants enrolled, 24 withdrew prior to completing 4 months of diary entries. Participants (n = 77) had a mean age of 37.5(7.5) years and were primarily white (82%) and well-educated (93%). They lived in 21 US states, and one in the UK. The majority (68%) completed at least 50% of their diary pages within 24 hours; 75% of all pages were completed within 2 days. At least 64 (83%) kept notes or printed pages when they lacked Internet access. In a follow-up survey (n = 67), 87% would have been willing to continue the diary for another 2 months; 69% had not previously participated in any research. Participants also reported that the study helped them better understand their headache patterns, that the study was a major commitment but worthwhile, and that they felt they had helped others by participating. CONCLUSION: The Internet-based headache diary is a feasible, acceptable data collection tool that can access geographically diverse populations who have not previously participated in research studies. Use of an Internet-based approach was found to be feasible for recruitment and retention of such diverse populations.

Twenty-four hours light exposure experiences in postpartum women and their 2-10-week-old infants: an intensive within-subject design pilot study.

BACKGROUND: Adequate light exposure is critical for entraining circadian rhythms, regulating sleep-wake cycles, and maintaining optimal mood. Yet, few studies have reported normative data on light exposure experiences in postpartum women and young infants; none has examined the two simultaneously. OBJECTIVES: The objective of this pilot study was to document the 24-h light exposure experiences in postpartum women and their infants. DESIGN: An intensive within-subject design was employed. SETTINGS: The participant's natural home environment. PARTICIPANTS: Twenty-four healthy mother-infant pairs were recruited from the general community in Seattle, USA. Two mother-infant pairs did not have complete data, resulting in a final sample size of 22 (12 female infants). METHODS: Mothers and infants wore a monitor to continuously record illumination levels for 7 days. Data were aggregated within subject to calculate summary measures of illumination exposure. Circadian patterns of light were examined using cosinor analysis. Pearson correlation was used to examine the relation between maternal and infant light exposure. RESULTS: Mothers spent 71.13 +/- 11.58% and infants spent 80.07 +/- 8.27% of their daytime hours (defined as 06:00-21:59) in an illumination level <50 lux. Mean minutes >1000 lux per day was 54 +/- 39 for mothers and 23 +/- 18 for infants. Maternal and infant light exposure exhibited a modest circadian pattern and a strong correlation, both in the timing of peak illumination exposure (r = 0.93, p < 0.01) and in the level of light exposure (r = 0.7 0 +/- 0.07). CONCLUSIONS: Postpartum women and infants experience low ambient light levels with short periods of bright light during the day. Whether this level of light is sufficient for optimal postpartum mood and infant circadian entrainment warrants further investigation. If higher levels of light were indeed necessary for postpartum women and young infants, increasing ambient light levels through the use of natural sunlight (i.e., walking outdoors) could be a simple and economic nursing intervention. The strong pattern synchrony between maternal and infant light exposure suggests that mothers play the primary role in providing a lighting environment suitable for infants to synchronize their circadian rhythms to a 24-h day.

Power spectral analysis of sleep EEG in twins discordant for chronic fatigue syndrome.

OBJECTIVE: The purpose of the study was to evaluate quantitative sleep electroencephalogram (EEG) frequencies in monozygotic twins discordant for chronic fatigue syndrome. METHODS: Thirteen pairs of female twins underwent polysomnography. During the first night, they adapted to the sleep laboratory, and during the second night, their baseline sleep was assessed. Visual stage scoring was conducted on sleep electroencephalographic records according to standard criteria, and power spectral analysis was used to quantify delta through beta frequency bands, processed in 6-s blocks. Data were averaged across sleep stage within each twin and coded for sleep stage and the presence or absence of chronic fatigue syndrome (CFS). A completely within-subjects repeated measure multivariate analysis of variance evaluated twin pairs by frequency band by sleep stage interactions and simple effects. The relationship between alpha and delta EEG was also assessed across twin pairs. RESULTS: No significant differences in spectral power in any frequency band were found between those with CFS and their nonfatigued cotwins. Phasic alpha activity, coupled with delta was noted in five subjects with CFS but was also present in 4/5 healthy twins, indicating this finding likely reflects genetic influences on the sleep electroencephalogram rather than disease-specific sleep pathology. CONCLUSIONS: The genetic influences on sleep polysomnography and microarchitecture appear to be stronger than the disease influence of chronic fatigue syndrome, despite greater subjective sleep complaint among the CFS twins. EEG techniques that focus on short duration events or paradigms that probe sleep regulation may provide a better description of sleep abnormalities in CFS.

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.

The role of centers in fostering interdisciplinary research.

This article describes the history of the University of Washington School of Nursing (UW-SON) Center for Women's Health and Gender Research (CWHGR) and its role in helping initiate and sustain interdisciplinary research. The growing focus on the need for interdisciplinary research has made it imperative that nursing scientists collaborate with colleagues in other health-related fields including medicine, public health, dentistry, and social work. The CWHGR increased interdisciplinary research activities through mentorship of faculty and trainees, the creation of core laboratory facilities, the award of pilot grant funding focused on interdisciplinary collaboration, consultation on research design and methods both within and outside the UW-SON, and the utilization of the Human Response Model for both biobehavioral and sociocultural research collaboration. Accomplishments as well as lessons learned related to interdisciplinary research during the 19 years of the UW-SON CWHGR are highlighted.

Polysomnography and self-reported sleep, pain, fatigue, and anxiety in children with active and inactive juvenile rheumatoid arthritis.

OBJECTIVE: To compare polysomnography (PSG) and self-reported sleep, symptoms (pain and fatigue), and anxiety between children with active and inactive juvenile rheumatoid arthritis (JRA) and examine relations among sleep, symptoms, and anxiety. METHODS: Two consecutive nights of PSG, self-reported sleep, and symptoms were obtained in 70 children 6-11 years of age with active (n = 35) or inactive (n = 35) JRA. RESULTS: On the second (study) night, PSG and self-reported sleep variables were not different, but pain and fatigue were significantly higher (both p <.02) in children with active compared to inactive disease. In a stepwise regression, age, medications, disease status, anxiety, evening pain, total sleep time, and arousals explained 36% of the variance in fatigue and age, disease status, and evening pain were significant (all p <.04) predictors of fatigue. All children showed longer sleep latency and reduced sleep efficiency on the first night in the laboratory. CONCLUSIONS: Sleep was not altered in children with active JRA, however, the "first night effect" suggests that valid laboratory sleep assessments require an adaptation night.

Actigraphic sleep and daytime naps in adolescent girls with chronic musculoskeletal pain.

OBJECTIVES: A descriptive pilot study to examine sleep and daytime naps in adolescent girls with chronic musculoskeletal (MSK) pain. METHODS: Seventeen girls (14.9 +/- 2.0 years) completed questionnaires on anxiety and depressive symptoms during their clinic visit, and maintained a sleep diary and wore an actigraph for 7 days. Parents completed a daily diary of their teen's medications and approaches used to ease pain. RESULTS: Average nighttime sleep was 7.2 hr by actigraphy. All participants had mean sleep efficiency <90%. In diaries, 76.5% of the girls reported daytime naps; five girls reported more than three days with naps and more naps were associated with lower sleep efficiency and total nighttime sleep. CONCLUSIONS: Adolescent girls with chronic MSK pain may sleep fewer hours at night than is recommended and nap in the daytime to compensate for insufficient nighttime sleep.

The impact of a 4-hour sleep delay on slow wave activity in twins discordant for chronic fatigue syndrome.

OBJECTIVES: Chronic fatigue syndrome (CFS) has been associated with altered amounts of slow wave sleep, which could reflect reduced delta electroencephalograph (EEG) activity and impaired sleep regulation. To evaluate this hypothesis, we examined the response to a sleep regulatory challenge in CFS. DESIGN: The first of 3 consecutive nights of study served as laboratory adaptation. Baseline sleep was assessed on the second night. On the third night, bedtime was delayed by 4 hours, followed by recovery sleep. Total available sleep time was held constant on all nights. SETTING: A research sleep laboratory. PARTICIPANTS: 13 pairs of monozygotic twins discordant for CFS. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Power spectral analysis quantified slow wave activity (SWA) in the 0.5-3.9 Hz band in successive NREM periods (stage 2, 3, or 4) on each night. To ensure comparability, analyses were restricted to the first 4 NREM periods on each night. Data were coded for NREM period and twin pair. Repeated-measures analysis of variance (ANOVA) contrasted sleep delay effects across NREM periods between twin pairs. A second ANOVA calculated the SWA in each NREM period in recovery sleep relative to baseline SWA. The 2 groups of twins were similar on baseline SWA power. After sleep delay, CFS twins exhibited significantly less SWA power in the first NREM period of recovery sleep and accumulated a smaller percentage of SWA in the first NREM period than their co-twins. CONCLUSIONS: CFS is associated with a blunted SWA response to sleep challenge, suggesting that the basic sleep drive and homeostatic response are impaired.

Ovarian steroids and premenstrual symptoms: a comparison of group differences and intra-individual patterns.

To examine the relationship of gonadal hormone and symptom patterns across the menstrual cycle, women screened for 2-3 cycles completed an intensive study cycle; 26 had a low-severity symptoms (LS), 20, a premenstrual syndrome (PMS), and 26, a premenstrual magnification pattern (PMM). All completed daily symptom diaries and collected late afternoon urine samples which were assayed for pregnanediol and estradiol for that cycle. The PMS and PMM groups had significantly more positive cross-correlations of pregnanediol and symptoms than the LS group. Women in all groups had similar levels of estradiol and pregnanediol. Women with PMS and PMM patterns responded to progesterone differently than women with LS patterns: thus the former groups may not benefit from hormone therapies.

Associations between fracture incidence and use of depot medroxyprogesterone acetate and anti-epileptic drugs in women with developmental disabilities.

PURPOSE: We sought to evaluate any association between incidence of osteoporotic fractures and use of depot medroxyprogesterone acetate (DMPA) and/or anti-epileptic drugs (AEDs) among women and girls with developmental disabilities. METHODS: Cross-sectional population-based observational study of all noninstitutionalized females with developmental disabilities age >/=13 who received fee-for-service Medicaid in Washington State during 2002 (n = 6,773), using administrative data. MAIN FINDINGS: In a sample of 6,773 females, 140 women (2%) had an osteoporotic fracture during 2002. Among 340 users of DMPA, 13 (3.8%) had an osteoporotic fracture with an odds ratio of 2.4 (95% confidence interval [CI], 1.3-4.4) for fracture compared to nonusers. Among 1,909 users of AEDs, 60 (3.1%) had an osteoporotic fracture with an odds ratio of 1.9 (95% CI, 1.3-2.6) for fracture compared to nonusers. We controlled for use of drugs (DMPA or AEDs), age and race (as white or other racial and ethnic groups). CONCLUSIONS: Use of either AEDs or DMPA by women with developmental disabilities is associated with significantly increased incidence of fracture. Women and girls who have developmental disabilities may be poor candidates for DMPA use owing to increased risk of fractures. Further research is indicated to 1) determine the specific risks profile of DMPA for this population, 2) explore alternative means of managing significant menstrual problems and contraceptive needs in this population, and 3) screen current and previous users of DMPA and chronic users of AEDs for osteoporosis risk, regardless of age.