Sleep, screen time and behaviour problems in preschool children: an actigraphy study.

Inadequate sleep and excessive exposure to media screens have both been linked to poorer mental health in youth. However, the ways in which these interact to predict behaviour problems have yet to be examined using objective sleep measurement. The lack of objective evidence for these relationships in young children has recently been defined by the World Health Organization (2019) as a gap in the field. We thus aimed to test the interacting effects of screen exposure and objectively measured sleep on behaviour problems in the preschool age. A total of 145 children aged 3-to-6-years participated in this cross-sectional study. Sleep was assessed objectively using actigraphy for 1-week, and subjectively using parent-reported daily sleep diaries. Parents reported the child's daily duration of screen exposure, and completed the Strengths and Difficulties Questionnaire. Results showed that actigraphic sleep duration, timing and efficiency were associated with screen exposure. The link between screen time and behaviour problems was moderated by sleep duration, as it was significant only for children with sleep duration of 9.88 h or less per night. Sleep duration also moderated the relation between screen time and externalizing-but not internalizing-problems. Hence, the combination of increased screen exposure and decreased sleep duration may be particularly adverse for child mental health. While these key relationships should be further examined in longitudinal and experimental investigations, our findings shed light on their complexity, underscoring the importance of the moderating role of sleep.

Behavioral interventions for infant sleep problems: the role of parental cry tolerance and sleep-related cognitions.

STUDY OBJECTIVES: This study tested whether parental cry tolerance (PCT) and distress-attribution cognitions predict outcomes of behavioral interventions for infant sleep problems. It additionally examined intervention effects on these parental factors. METHODS: Participants were 91 infants aged 9-18 months (61% boys) with sleep-related problems and their parents. Families were randomized to 1 of 2 behavioral interventions for infant sleep problems: Checking-in or Camping-out. Assessments were completed at baseline and 1-month post-treatment. Infant sleep was assessed using actigraphy and parent reports on the Brief Infant Sleep Questionnaire. PCT was measured using the Intervention Delay to Infant Crying Video laboratory paradigm, and parental distress-attribution cognitions were assessed via the Infant Sleep Vignettes Interpretation Scale. RESULTS: Higher PCT and lower parental distress-attribution cognitions at baseline predicted greater improvement in parent-reported sleep problems post-treatment, and higher PCT additionally predicted larger reductions in the number of reported nighttime awakenings. Moreover, PCT increased, and distress-attribution decreased, following the interventions. CONCLUSIONS: Parent factors both predict and are predicted by behavioral interventions for infant sleep problems. This study's findings suggest that parents with low cry tolerance and high distress-attribution cognitions derive less benefit from these interventions and may thus require augmented care. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Interventions for sleep problems in early childhood; URL: https://clinicaltrials.gov/ct2/show/NCT01489215;Identifier: NCT01489215.

Behavioral interventions for pediatric insomnia: one treatment may not fit all.

STUDY OBJECTIVES: Behavioral interventions for pediatric insomnia are cost-effective and benefit most families, but there is no evidence indicating which treatments are most suitable for specific patient populations. This randomized controlled trial evaluated the moderating role of infant separation anxiety in two brief interventions for infant sleep problems. METHODS: Ninety-one infants aged 9-18 months (61% boys) with pediatric insomnia were randomized to either Checking-in, a Graduated extinction protocol which involves gradual separation from parents, or to the Camping-out intervention, in which parental presence is maintained. Sleep was measured using actigraphy and parent reports. Infant separation anxiety was observed in the laboratory. Assessments were completed at baseline, post-treatment and 6-month follow-up. RESULTS: Improvement in sleep was demonstrated following both interventions and maintained at follow-up. Separation anxiety did not change significantly following treatment. Infant separation anxiety moderated treatment efficacy, with greater benefit for infants with high separation anxiety in the Camping-out compared to the Checking-in intervention. CONCLUSIONS: This study provides support for considering infant separation anxiety in the effort to personalize treatment for pediatric insomnia. Pediatricians should incorporate evaluation of infant separation anxiety to assessment processes, and favor more gentle treatment approaches, such as Camping-out, over Graduated extinction for highly anxious infants. CLINICAL TRIAL REGISTRATION: NCT01489215.

Links between infant sleep and parental tolerance for infant crying: longitudinal assessment from pregnancy through six months postpartum.

BACKGROUND: Low parental tolerance for crying has been associated with infant sleep problems, yet the directionality of this link remained unclear. This longitudinal study aimed to assess the synchronous and prospective bidirectional links between parental cry-tolerance, soothing, and infant sleep from pregnancy through six months postpartum. METHODS: Sixty-five couples were recruited during pregnancy and assessed for cry-tolerance using a paradigm in which participants were shown a videotape of a crying infant and were asked to stop the video when they feel it is necessary to intervene. Infant sleep was assessed objectively using actigraphy for five nights at three and six months postpartum. Parental soothing techniques were reported by parents at both assessment points, and cry-tolerance was reassessed at six months. RESULTS: Concomitant associations were found between maternal cry-tolerance and infant sleep at six months, indicating that lower maternal cry-tolerance was correlated with poorer actigraphic sleep quality. Furthermore, Structural Equation Modeling analyses yielded significant prospective associations, showing that lower cry-tolerance at pregnancy predicted better infant sleep at three months, whereas more disrupted sleep at three months predicted lower cry-tolerance at six months. Moreover, fathers showed higher cry-tolerance compared to mothers, and parents became more similar to each other across time in their reactivity to infant crying. CONCLUSION: Consistent with the transactional model of infant sleep, the findings of this study highlight the role of parental cry-tolerance in infant sleep development, and demonstrate bidirectional links between this construct and infant sleep throughout the first six months of life.

Externalizing Behaviors and Callous-Unemotional Traits: Different Associations With Sleep Quality.

Study Objectives: Sleep quality is associated with different aspects of psychopathology, but relatively little research has examined links between sleep quality and externalizing behaviors or callous-unemotional traits. We examined: (1) whether an association exists between sleep quality and externalizing behaviors; (2) whether anxiety mediates this association; (3) whether callous-unemotional traits are associated with sleep quality. Methods: Data from two studies were used. Study 1 involved 1556 participants of the G1219 study aged 18-27 years (62% female). Questionnaire measures assessed sleep quality, anxiety, externalizing behaviors, and callous-unemotional traits. Study 2 involved 338 participants aged 18-66 years (65% female). Questionnaires measured sleep quality, externalizing behaviors, and callous-unemotional traits. In order to assess objective sleep quality, actigraphic data were also recorded for a week from a subsample of study 2 participants (n = 43). Results: In study 1, poorer sleep quality was associated with greater externalizing behaviors. This association was partially mediated by anxiety and moderated by levels of callous-unemotional traits. There was no significant relationship between sleep quality and callous-unemotional traits. In study 2, poorer sleep quality, as assessed via self-reported but not objective measures, was associated with higher levels of externalizing behaviors. Furthermore, in study 2, better sleep quality (indicated in both questionnaires and actigraphy measures: lower mean activity, and greater sleep efficiency) was associated with higher levels of callous-unemotional traits. Conclusions: Self-reports of poorer sleep quality are associated with externalizing behaviors, and this association is partially mediated by anxiety. Callous-unemotional traits are not associated with poor sleep and may even be related to better sleep quality. This is an exceptional finding given that poor sleep quality appears to be a characteristic of most psychopathology.

Cognitive-behavioral versus non-directive therapy for preschoolers with severe nighttime fears and sleep-related problems.

OBJECTIVE: To compare the efficacy of a developmentally appropriate cognitive-behavioral therapy protocol for preschoolers with severe nighttime fears and sleep-related problems, with an active control treatment. METHODS: Ninety children aged four to six years (63% boys) with severe nighttime fears and their parents were randomized to either cognitive-behavioral therapy including parent involved play (CBT-PIP) or to a structurally equivalent non-directive treatment (TEPT; triadic expressive play therapy). Treatment conditions were also equivalent in parent- and child-rated credibility and expectancy, and in therapist-rated compliance. Children and parents were assessed at baseline, during the first intervention week and four weeks after treatment. Measures included actigraphy, daily sleep logs, structured diagnostic interviews and parent questionnaires. RESULTS: Significant reductions were observed in nighttime fears and objectively and subjectively measured sleep disruptions in both intervention groups following treatment. Parent reports indicated more advantageous outcomes for CBT-PIP compared to TEPT, with greater reductions in sleep problems and co-sleeping as well as higher customer satisfaction in the former group. CONCLUSIONS: While CBT-PIP showed no significant advantage compared to the active control in reducing fears or in improving objectively measured sleep, it was significantly more beneficial in reducing the adverse behavioral features of nighttime fears.

Young child and maternal sleep in the Middle East.

BACKGROUND: This study aimed to characterize sleep patterns and sleep problems in a large sample of infants and toddlers (from birth to three years) and their mothers in Arabic-speaking families in the Middle East and compare the results to those living in predominantly Asian and predominantly Caucasian countries/regions. METHODS: Mothers of 669 young children (from Saudi Arabia, Egypt, Algeria, United Arab Emirates, Jordan, Morocco, Iraq, Kuwai, Oman, Palestinian territories, Libyan Arab Jamahiriya, Bahrain, Israel, and other Arab countries) completed an Internet-based expanded version of the Brief Infant Sleep Questionnaire, Daily Infant Mood Scale, and the Pittsburgh Sleep Quality Index. RESULTS: Overall, children and their mothers in the Middle East slept on a shifted schedule, with late bedtimes and waketimes compared to those from predominantly Asian and predominantly Caucasian countries/regions. Almost all families room-shared with their children, although less than half bed-shared. A significant percentage of parents perceived that their child had a sleep problem (37%), with a high prevalence of poor sleep in mothers (72%). Parent-reported child mood was modestly associated with sleep patterns but more so with parent-perceived sleep problems. Parent-perceived sleep problems in their young child were predicted by bedtimes, prevalence of a bedtime routine, and night wakings. CONCLUSIONS: Overall, both young children and their mothers in the Middle East have a delayed sleep schedule, going to bed late in the evening and waking up late in the morning. Sleep was associated with mood outcomes, with bedtimes, bedtime routines, and falling asleep independently predicting sleep outcomes. The high prevalence of sleep problems in both the infants and toddlers and their mothers supports the need for sleep to be addressed by pediatric and adult healthcare practitioners.

Parental behaviors and sleep/wake patterns of infants and toddlers in Hong Kong, China.

BACKGROUND: To describe the sleep patterns of children below 36 months in Hong Kong, and evaluate the associations between parental behaviors and childhood sleep/wake patterns. METHODS: Parents of 1049 infants and toddlers completed an internet-based expanded version of the Brief Infant Sleep Questionnaire. RESULTS: Total sleep duration (P<0.001), frequency (P<0.001) and duration (P<0.001) of nocturnal awakenings decreased with age, whereas the longest sleep duration (P<0.001) and nocturnal sleep duration (P<0.001) increased with age. Children who room- or bed-shared with parents had later bedtimes (P<0.001), but similar sleep duration compared with those who had a separate sleep location. Falling asleep independently was associated with longer nocturnal sleep duration (P<0.001) and less sleep awakenings (P<0.001). Full-time employment of parents was associated with shorter total sleep duration of children (P<0.001). Although breastfeeding was associated with more nocturnal awakenings (P<0.001), no association was detected between breastfeeding and shorter sleep duration in children. CONCLUSIONS: As infants and toddlers develop, their sleep consolidates. Falling asleep independently was associated with longer nocturnal sleep duration and fewer sleep awakenings, whereas sleep location was not. This is an important finding, especially for families with limited living space where parent/child room- or bed-sharing cannot be avoided.

Sleep and Social-Emotional Development in Infants and Toddlers.

The aim of this study was to examine the cross-sectional and longitudinal relationships among variables related to sleep patterns and both social-emotional problems (i.e., internalizing, externalizing, and dysregulation) and healthy social development (i.e., social competence). Assessments were completed at 6, 12, and 18 months across 5 cohorts of children for a total of 117 mother-child dyads. Mothers completed the Brief Infant Sleep Questionnaire at 6, 12, and 18 months, as well as the Infant Toddler Social Emotional Assessment at 12 and 18 months. Later bedtimes and less total sleep across the 24-hr period predicted higher internalizing problem scores, which includes indices of depression/withdrawal, general anxiety, separation distress, and inhibition. In contrast, sleep fragmentation was minimally associated with decreased social competence but not with any negative social-emotional outcomes. These results indicate that sleep patterns, primarily later bedtimes and less total sleep, appear to be associated with and predictive of social-emotional problem areas, namely, internalizing issues, in infants and toddlers. These findings add to the growing literature on the role of sleep in early social-emotional development and suggest that sleep schedule and duration should be addressed in clinical assessment and interventions for infant sleep.

Low parental tolerance for infant crying: an underlying factor in infant sleep problems?

Parenting behaviours play a major role in the evolution of infant sleep. Sleep problems in infancy have been associated with excessive parental involvement at night-time, and with shorter delays in response to infant night wakings and signalling. Infant crying and sleep problems are linked, yet little is known about the impact of parental responses to crying on infant sleep patterns. This study examined the hypothesis that lower parental tolerance for crying is associated with infant sleep problems. We studied 144 married couples divided into three groups: parents of infants suffering from night-waking problems (i.e. the clinical group), parents of infants without sleep problems and childless couples. Crying tolerance was assessed using questionnaires, audio recordings of crying infants and using a novel paradigm, in which participants were shown a video of a crying infant and asked when they would intervene. Parents in the clinical group demonstrated shorter intervention delays in the crying infant clip (group effect: P < 0.0001), and tended to attribute more distress to the crying infants compared to parents in both control groups (P < 0.05). Additionally, women demonstrated lower tolerance for infant crying on most measures compared to men. Our results suggest that parents of sleep-disturbed infants appear to have lower tolerance for infant crying, which may be a predisposition underlying their excessive involvement in soothing their infants to sleep which may lead to the development of sleep problems. These preliminary findings should be explored further to assess their clinical validity and utility.

Sleep Patterns among South Korean Infants and Toddlers: Global Comparison.

The purpose of this study was to examine sleep patterns in a large sample of infants and toddlers (ages birth to 36 months) in Korea, and to compare sleep patterns, sleep problems, sleep ecology, and parental behaviors to global sleep data on young children in both predominantly Asian (P-A) and predominantly Caucasian (P-C) countries/regions. We additionally examined parent and child demographic information, parental behaviors, and aspects of the sleep ecology as predictors of sleep patterns among infants and toddlers in Korea. Parents/caregivers of 1,036 Korean infants and toddlers completed an expanded, internet-based version of the brief infant sleep questionnaire. Consistent with other studies of sleep in early childhood, sleep/wake patterns became increasingly consolidated with older child age for the Korea sample. Compared to both P-A and P-C infants and toddlers, children in Korea had the latest bedtimes, shortest total sleep and daytime sleep durations, and the least frequent rates of napping. Even though half of parents perceive their children's sleep problematic, parental perceptions of severe child sleep problems were the lowest. Within Korea, breastfeeding and bottle-feeding at sleep resumption were associated with increased nocturnal awakenings. Evening television viewing was associated with later bedtimes, which may have implications for sleep hygiene recommendations in clinical practice. The current study provides important information about sleep/wake patterns, parental behaviors, and aspects of the sleep ecology for infants and toddlers for physicians to support healthy sleep in Korea.

Annual Research Review: Sleep problems in childhood psychiatric disorders--a review of the latest science.

BACKGROUND: Hippocrates flagged the value of sleep for good health. Nonetheless, historically, researchers with an interest in developmental psychopathology have largely ignored a possible role for atypical sleep. Recently, however, there has been a surge of interest in this area, perhaps reflecting increased evidence that disturbed or insufficient sleep can result in poor functioning in numerous domains. This review outlines what is known about sleep in the psychiatric diagnoses most relevant to children and for which associations with sleep are beginning to be understood. While based on a comprehensive survey of the literature, the focus of the current review is on the latest science (largely from 2010). There is a description of both concurrent and longitudinal links as well as possible mechanisms underlying associations. Preliminary treatment research is also considered which suggests that treating sleep difficulties may result in improvements in behavioural areas beyond sleep quality. FINDINGS: To maximise progress in this field, there now needs to be: (a) greater attention to the assessment of sleep in children; (b) sleep research on a wider range of psychiatric disorders; (c) a greater focus on and examination of mechanisms underlying associations; (d) a clearer consideration of developmental questions and (e) large-scale well-designed treatment studies. CONCLUSIONS: While sleep problems may sometimes be missed by parents and healthcare providers; hence constituting a hidden risk for other psychopathologies - knowing about these difficulties creates unique opportunities. The current excitement in this field from experts in diverse areas including developmental psychology, clinical psychology, genetics and neuropsychology should make these opportunities a reality.

Infant Sleep Predicts Attention Regulation and Behavior Problems at 3-4 Years of Age.

This longitudinal study assessed the role of early sleep patterns in predicting attention regulation and behavior problems. Sleep of 43 infants was assessed using actigraphy at 12 months of age and then reassessed when the children were 3-4 years old. During this follow-up, their attention regulation and behavior problems were also assessed using a computerized test and parental reports. Lower quality of sleep in infancy significantly predicted compromised attention regulation and behavior problems. These findings underscore the need to identify and treat early sleep problems.

Assessing fears of preschool children with nighttime fears by a parent version of the fear survey schedule for preschool children.

BACKGROUND: Although excessive fears are common in preschool children, validated assessment tools for this age are lacking. Our aim was to modify and provide preliminary evidence of the utility of a preschoolers' fear screening tool, a parent-reported Fear Survey Schedule for Preschool Children (FSS-PC). METHODS: 109 Israeli preschool children (aged 4-6 years) with chronic night time fears (NF) and 30 healthy children (controls) participated. The FSS-PC analysis included: 1) internal reliability, 2) correlations between FSS-PC scores and Child Behavior Checklist (CBCL) measures, 3) differences between NF and a comparison sample of FSS-PC scores, and 4) FSS-PC sensitivity in detecting change in NF following an intervention for NF. RESULTS: There were low-to-medium positive correlations between the FSS-PC scores and several internalizing scales of the CBCL measures. FSS-PC scores in the NF group were significantly higher than the control children's score. FSS-PC scores had adequate internal reliability and were also sensitive for detecting significant changes in fear levels following behavioral interventions. LIMITATIONS: Unique cultural and environmental circumstances and specific study group. CONCLUSIONS: This new version of the FSS-PC may provide clinicians with a novel and useful screening tool for early assessment of fear- and anxiety-related phenomena of preschool children.

Relationship Between Child and Maternal Sleep: A Developmental and Cross-Cultural Comparison.

The aim of this study was to assess the relationship between young children's sleep and maternal sleep from both a developmental and a cross-cultural perspective. Mothers of 10,085 young children completed the Brief Infant/Child Sleep Questionnaire and the Pittsburgh Sleep Quality Index. Overall, there were significant relationships between maternal and child sleep for bedtime, waketime, number of night wakings, and total nighttime sleep time across ages and cultures, although these relationships were stronger with younger children than preschool-aged children. Mothers report that their child's sleep pattern significantly impacts their sleep and daytime function, and they do not feel confident in managing their child's sleep pattern. Thus, interventions to improve children's sleep and develop good sleep habits, especially in early childhood, are likely to improve the quality of life of the whole family.

I. Sleep and development: introduction to the monograph.

Literature on sleep and child development is growing rapidly in exciting new directions across several disciplines and with this comes a need for guiding conceptual principles and methodological tools. In this introductory chapter, the importance of sleep for child development across multiple domains is highlighted. The aims of this monograph are presented and pertain to the need to consider and integrate theory and research across multiple disciplines and use state-of-the-art methodologies. A developmental ecological systems perspective adapted to sleep illustrates the multiple levels of influence and their importance in the study of child sleep and development. A focal aim is to provide examples of longitudinal studies linking sleep with child development, which are presented in seven chapters of this volume.

Iii. Sleep assessment methods.

Sleep is a complex phenomenon that could be understood and assessed at many levels. Sleep could be described at the behavioral level (relative lack of movements and awareness and responsiveness) and at the brain level (based on EEG activity). Sleep could be characterized by its duration, by its distribution during the 24-hr day period, and by its quality (e.g., consolidated versus fragmented). Different methods have been developed to assess various aspects of sleep. This chapter covers the most established and common methods used to assess sleep in infants and children. These methods include polysomnography, videosomnography, actigraphy, direct observations, sleep diaries, and questionnaires. The advantages and disadvantages of each method are highlighted.

Reactivity and sleep in infants: a longitudinal objective assessment.

Sleep patterns and temperament in the first year of life are closely related. However, research utilizing objective, rather than subjective measurements of sleep and temperament is scarce and results are inconsistent. In addition, a relative lack of longitudinal data prevents inference of causality between the two constructs. In this study, infant sleep was objectively assessed among 95 infants at 3, 6, and 12 months-of-age with an actigraph in the home setting. Reactivity to sound, light, and touch, a specific aspect of temperament, was behaviorally assessed at 3 and 6 months, both during sleep (at home) and during waking (at the laboratory). Expected maturational trends were recorded in sleep, with a temporal increase in sleep efficiency and percent of motionless sleep. Quadratic (i.e., inverse U shape) relations were found, especially among girls, when predicting change in sleep by reactivity thresholds, suggesting that both hyposensitive and hypersensitive infants are at risk for poor sleep quality. These are the first research findings suggesting that low reactivity in infancy might be associated with compromised sleep quality. The observed nonlinear effects may account for null or inconsistent results in previous studies that explored only linear associations between temperament and sleep. Future studies should address both extremes of the temperament continuum when exploring relations with sleep patterns.