Featured Article: Multiple Comorbid Conditions, Sleep Quality and Duration, and Academic Performance in Urban Children With Asthma.

Objective: Common comorbid medical conditions including allergic rhinitis (AR), obesity, and sleep disordered breathing (SDB) have been linked with asthma exacerbations; however, these conditions also impact sleep and academic functioning. The current study sought to examine unique and combined associations of these common comorbidities on sleep and academic performance among urban minority children with persistent asthma. We expected additional comorbid diagnoses would be associated with poorer sleep and academic functioning. Method: Urban children 7-9 years old (n = 249) with persistent asthma from African American, Latino, and non-Latino White backgrounds participated in this cross-sectional study. Asthma and AR were assessed using guidelines-based approaches. Overweight/obesity was assessed using body mass index and parents reported on SDB risk. Sleep quality (sleep efficiency) and sleep duration were assessed via 4 weeks of actigraphy. A cumulative risk index (CRI) score of asthma-related comorbidities (i.e., number of comorbidities for which each child met criteria) was calculated. Results: Comorbid conditions were prevalent (AR, 85%; overweight/obese, 39%; SDB risk, 44%). Lower SDB risk and better AR control were both associated with fewer school absences. A higher CRI score was associated with shorter sleep duration and more absences. For children with 1 comorbid condition, better lung function was associated with better sleep efficiency. Conclusion: Findings suggest increased risk of shorter sleep and more frequent school absences among urban minority children with asthma and more comorbid conditions. Assessment and treatment of this high-risk group must consider how comorbid conditions exacerbate children's asthma and may affect sleep and daytime functioning.

Parent-Reported Problematic Sleep Behaviors in Children with Comorbid Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder.

BACKGROUND: Sleep problems are frequent and well documented in children with Autism Spectrum Disorders (ASD), children with Attention Deficit/Hyperactivity Disorder (ADHD) and children with internalizing problems, however limited work has examined sleep problems in children presenting with comorbid ASD/ADHD. In healthy children, sleep problems negatively impact social, emotional, and academic functioning. The current study sought to examine diagnostic severity as predictors of sleep problems in children with comorbid ASD/ADHD. Additionally, the association between sleep and "real-life" functional domains (i.e., intellectual functioning, academic achievement, and executive functioning) were assessed. METHOD: Sleep, internalizing difficulties, intellectual functioning, academic achievement and executive functioning were assessed in 85 children with who carried the dual diagnoses of ASD and ADHD. RESULTS: Internalizing difficulties, rather than ASD or ADHD symptom severity, was the most consistent predictor of problematic sleep behaviors (i.e., nightmares overtiredness, sleeping less than other children, trouble sleeping, and Total Problematic Sleep Behaviors) in this sample. Further, parent report of problematic sleep behaviors was significantly associated with functional domains after controlling for ASD, ADHD, and internalizing symptoms. CONCLUSIONS: Results suggest that internalizing symptoms are associated with problematic sleep behaviors in children with comorbid ASD/ADHD and may have implications for the "real-life" functioning among children with comorbid ASD/ADHD.

Childhood Bedtime Problems Predict Adolescent Internalizing Symptoms Through Emotional Reactivity.

OBJECTIVE: Sleep problems are frequent in children and robustly predict internalizing symptoms in adolescence and adulthood. Longitudinal investigations have nonetheless used broad measures of childhood sleep problems, precluding understanding of the specific sleep problems that presage affective disturbances. Similarly, prospective examinations of mechanistic variables linking early sleep with subsequent internalizing symptoms are lacking. METHOD: Childhood bedtime and nighttime waking problems were examined as independent predictors of adolescent internalizing symptoms within a community sample from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (N = 1,089). The mediational role of emotional reactivity in late childhood also was examined. RESULTS: Bedtime but not nighttime waking problems significantly predicted adolescent internalizing problems. This relationship was partially explained by child emotional reactivity. CONCLUSIONS: Some childhood sleep problems may more reliably predict later internalizing symptoms than others. Temperamentally based emotional reactivity may potentiate affective risk associated with childhood sleep difficulties.

Things that Go Bump in the Night: Frequency and Predictors of Nightmares in Anxious and Nonanxious Children.

Frequency and predictors of nightmares among children 7-11 years old with generalized anxiety disorder (GAD; n = 42) and no diagnosis (n = 44) were examined using both prospective and retrospective child and parent reports. Both children with GAD and their parents reported significantly more nightmares than controls based on retrospective reports, but the groups did not differ when nightmares were assessed daily across a one-week prospective period. Females reported more nightmares than males according to prospective assessment only. Controlling for sex and group, child sleep anxiety and presleep somatic arousal predicted parent but not child report of nightmares. Results suggest both clinically anxious youth and their parents overestimate the occurrence of nightmares, yet factors influencing retrospective accounts appear to differ across informants.

Sleep in Children and Adolescents with Obsessive-Compulsive Disorder.

Sleep problems are not a core feature of obsessive-compulsive disorder (OCD), but emerging empirical data indicate some form of sleep disruption to be highly common. Available research in both adult and child patients is limited in several important ways, including the use of subjective reports (particularly in children), high rates of comorbid depression, and concurrent use of psychotropic medication. The presence of sleep disruption in OCD patients may compound severity and impairment of the disorder. More research is needed to fully understand the nature and consequences of sleep-wake disruption in children with OCD.

The Parent-Child Sleep Interactions Scale (PSIS) for preschoolers: factor structure and initial psychometric properties.

STUDY OBJECTIVES: Given the high prevalence of sleep problems in early childhood and the significant impact of parenting on children's sleep, the current study aimed to determine the factor structure and psychometric properties of a new measure for assessing sleep-related parenting behaviors and interactions among preschool-aged children-The Parent-Child Sleep Interactions Scale (PSIS). METHODS: Data was collected among parents of 209 preschool-aged children in two diverse metropolitan areas. All parents completed demographic questionnaires, the Parent-Child Sleep Interaction Scale (PSIS), and the Child Behavior Checklist (CBCL). A subset of parents completed structured interviews using the Preschool Age Psychiatric Assessment (PAPA). Following data reduction procedures, exploratory factor analysis (EFA) using principal axis extraction and oblique rotation was conducted, and internal consistency was assessed. Associations between PSIS scores and sleep problems based on the CBCL and PAPA as well as child sleep problems during infancy were examined. Differences based on demographic variables including race/ethnicity were also investigated. RESULTS: EFA revealed a three-factor solution explaining 60% of the variance in total PSIS scores. Individual factors based on 12 items were labeled Sleep Reinforcement, Sleep Conflict, and Sleep Dependence. Internal consistency for all subscales and total PSIS scores was acceptable. PSIS subscales were positively correlated with both CBCL and PAPA Sleep Problems. Sleep problems during the first year of life were associated with Sleep Conflict and total PSIS scores. Significant differences in PSIS scores based on race/ ethnicity were found. CONCLUSIONS: The PSIS shows promise as a valid measure of sleep-related parent/child behaviors and interactions among preschoolers.

Polysomnographic sleep patterns of non-depressed, non-medicated children with generalized anxiety disorder.

BACKGROUND: Polysomnographic (PSG) studies of children with psychiatric illness have primarily focused on depressed samples. Children with generalized anxiety disorder (GAD) report high rates of sleep problems yet investigation of objective sleep patterns in non-depressed children with GAD are unavailable. Identification of unique clinical features linking early GAD with sleep disturbance, including possible HPA activation during the pre-sleep period, is needed to inform effective treatments. METHOD: Thirty non-medicated, pre-pubescent children (ages 7-11 years) were assessed including 15 children with GAD and 15 matched healthy controls. Anxious children had GAD as their primary diagnosis and did not meet criteria for secondary mood disorders. All participants underwent structured diagnostic assessment and laboratory-based polysomnography (PSG). State anxiety and salivary cortisol were assessed prior to light out on the PSG night. RESULTS: Children with GAD showed significantly increased sleep onset latency and reduced latency to rapid eye movement (REM) sleep compared to controls. Marginal differences in the form of reduced sleep efficiency and increased total REM sleep also were found in the GAD group. Pre-sleep anxiety and cortisol levels did not differ between the two groups. LIMITATIONS: A small sample size, time-limited assessment of cortisol, and possible first night effects should be considered. CONCLUSIONS: Results of this study provide initial evidence of PSG-based differences in children with GAD compared to controls. Follow-up studies are needed to explore the course of sleep alterations and whether targeting sleep problems early in the course of GAD might improve clinical outcomes.