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

Sleepless nights, troubled futures: The association between insufficient sleep and child flourishing

OBJECTIVE

To examine associations between sleep and flourishing among children ages 0-5 years in the United States and whether these differ by age, developmental needs, and family resilience.

STUDY DESIGN AND METHODS

Cross-sectional data from the 2020-2021 National Survey of Children's Health (N = 31,095) were used with survey-weighted logistic regression to explore associations between insufficient sleep (defined as not meeting age-recommended daily sleep guidelines: 12-16 h for 4- to 12-month-olds, 11-14 h for 1- to 2-year-olds, and 10-13 h for 3- to 5-year-olds) and flourishing (using four markers combined and categorized into two groups). Tests of effect measure modification (EMM) were performed on the multiplicative and additive scales.

RESULTS

Weak but notable evidence was found that children with insufficient sleep had decreased odds of flourishing (aOR = 0.76; 95 % CI: 0.60, 1.00). No evidence of EMM by child age or family resilience was found. However, the sleep-flourishing association differed significantly by children's developmental needs, suggesting that the combined effect of sleep and developmental needs impact flourishing more than either factor alone.

CONCLUSIONS

Approximately 38 % of children ages 0-5 years in the United States are estimated to have insufficient sleep. This study provides evidence that insufficient sleep is associated with decreased flourishing among children with special health care needs (CSHCN).

FUTURE IMPLICATIONS

Increasing sleep interventions among children under five is warranted among children with special health care needs. The association between sleep and flourishing within specific CSHCN categories, including emotional, behavioral, or developmental (EBD) criteria, should be explored to optimize sleep policies.

Prospective associations of screen time at age 2 with specific behavioral subscales at age 3: a cohort study

BACKGROUND

We aim to discover which, if any, of the subscales of internalizing and externalizing behavioral problems at age 3 are still associated with screen time (ST) at age 2 after adjusting for behavioral problems scores at age 2.

METHODS

This study was conducted under the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study. Information was gathered prospectively, with 7207 mother-child pairs included in the analysis. Children's ST was categorized in hours a day at age 2 (<1, 1-<2, 2-<4, ≥4). We assessed children's behavioral problems using the Child Behavior Checklist for Ages 1½-5 (CBCL) at ages 2 and 3. 'Having behavioral problems' was defined by them being within a clinical range for internalizing behaviors (withdrawn, somatic complaints, anxious/depressed and emotionally reactive) and externalizing behaviors (attention problems and aggressive behaviors) at age 3. Continuous scores on each of the behavioral problem scales at age 2 were used as covariates.

RESULTS

Greater ST for children at age 2 was associated with specific subscales for emotionally reactive and aggressive behaviors at age 3.

CONCLUSIONS

This study found that ST is prospectively associated with some behavioral scales but not others.

Actigraphy-assessed sleep duration and quality and executive function in a sample of typically developing preschoolers

Sleep is essential for cognitive development and brain maturation during early childhood. Studies focused on preschool populations using objective measures of sleep are still scarce. The objective of this study was to examine the associations between objective measures of sleep duration and quality with executive functioning in a 133 non-clinical sample of Spanish participants (Mage = 60.33 months, SD = 9.04; ages 41-77 months; 51.1% girls). Sleep was assessed for five weeknights using actigraphy; Shape School task was applied to assess inhibition and cognitive flexibility; and Word Span task was used to assess working memory. The results revealed that relation between sleep and executive functioning was significant for inhibition and working memory. Preschoolers with higher sleep efficiency showed better results in executive functioning tasks after controlling for the effect of age. Additionally, age and sleep duration and quality variables were predictive of inhibition, working memory, and cognitive flexibility. These results suggest that the different dimensions of sleep could play an important role in the development of executive functions during preschool age. Therefore, improving sleep could lead to an improvement in children's executive functioning in both clinical and educational contexts.

Association between sleep duration and serum neurofilament light chain levels among adults in the United States

Background

Neurofilaments are neuron specific skeleton proteins maintaining axon transduction speed, leaked into cerebrospinal fluid and serum after axonal injury or neuron death. Sleep duration change has long related to many health issues but lack laboratory examination.

Methods

This study enrolled total 10,175 participants from 2013 to 2014 National Health and Nutrition Examination Survey and used a multi-variable linear model to analyze the relationship between sleep duration and serum neurofilament light chain (sNfL) level.

Results

There was a fixed relationship between sleep duration and sNfL level (β = 0.65, p = 0.0280). After adjusted for covariates, this relationship still (β = 0.82, p = 0.0052). Segmented regression showed that the turning point of sleep duration was 7 h 1 h decrease in sleep duration was significantly associated with -1.26 higher sNfL level (95 % CI: 2.25, -0.28; p = 0.0115) when sleep duration <7 h; however, 1 h increase in sleep duration was significantly associated with 3.20 higher sNfL level (95 % CI: 2.13, 4.27; p < 0.0001) when sleep duration >7 h. Furthermore, the stratified analysis indicated that the associations between sleep duration and sNfL level were stronger among those normal body mass index and trouble sleeping (p-interaction <0.0001 and 0.0003).

Conclusion

In summary, there was a J-shaped relationship between sleep duration and sNfL level in the United States of America representative group, these may suggest that extreme sleep duration can be deleterious judged by sNfL level. And still need large cohort study to determine the accurate relationship, and cluster analysis to infer the nervous disease connected with extreme sleep duration.

Evaluation of the association between excessive screen use, sleep patterns and behavioral and cognitive aspects in preschool population. A systematic review

In this review, we analyzed the possible relationship between the excessive use of screens and sleep patterns, and how this may affect certain behavioral and cognitive factors in preschool children. The selection, extraction and synthesis of the data were conducted according to PRISMA guidelines. The search was carried out in the electronic databases Medline (PubMed), PsycINFO (American Psychological Association), Scopus and Web of Science (WOS). Of the 597 articles initially identified, 13 met the inclusion criteria. The risk of bias of the articles selected was evaluated using a specific scale created for this purpose. The results found indicate that excessive use of screens is associated with a negative impact on the duration and quality of sleep-in preschoolers, and this worsening of sleep in infancy is related with a greater probability of the appearance of internalizing and externalizing behavioral problems and certain cognitive problems. The results also suggest that sleep could play a mediating or moderating role as a bioregulatory system that attenuates or increases the onset of behavioral and cognitive difficulties in those children most exposed to digital devices.

Examining the Bidirectional Associations Between Sleep Duration, Screen Time, and Internalizing Symptoms in the ABCD Study

PURPOSE

The likelihood of meeting sleep duration and screen time guidelines decreases as children develop toward adolescence. Simultaneously, the prevalence of internalizing symptoms increases. The purpose of this paper was to examine the bidirectional associations between sleep duration and screen time with internalizing symptoms in a one-year longitudinal study starting in late childhood.

METHODS

Participants were 10,828 youth (47.8% female) enrolled in the Adolescent Brain Cognitive Development Study. At baseline (mean age 9.9 years) and one-year follow-up (mean age 10.9 years), youth self-reported screen time for weekdays and weekend days. Responses were separately dichotomized as >2 versus ≤2 hours/day (meeting behavioral guidelines). Caregiver-reported youth sleep duration was dichotomized as <9 versus 9-11 hours/night (meeting behavioral guidelines). Caregivers reported internalizing symptoms via the child behavior checklist. The withdrawn/depressed, anxious/depressed, and somatic symptom child behavior checklist subscale t-scores were separately dichotomized as ≥65 (borderline clinical levels of symptoms and above) versus <65. Analyses were gender-stratified.

RESULTS

In females, longer baseline sleep duration was protective against withdrawn/depressed symptoms (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.4-0.8) and somatic complaints (OR 0.8, 95% CI 0.6-0.97) one year later. In females, greater baseline weekend screen time was associated with increased risk of withdrawn/depressed symptoms (OR 1.6, 95% CI 1.1-2.2) one year later. No other significant associations were observed.

DISCUSSION

Longitudinal associations between sleep duration, weekend screen time, and internalizing symptoms were unidirectional (behavior preceding internalizing symptoms), among females only, and specific to withdrawn/depressed and somatic symptoms. These prospective study findings warrant attention and inform future research in this cohort.

Maternal Perceptions of Evidence-Based Early Childhood Sleep Health Promotion Recommendations: An Explanatory Sequential Study

OBJECTIVES

The purpose of this explanatory sequential design study was to better understand caregivers' perceptions about and interest in evidence-based early childhood sleep health promotion recommendations.

METHOD

A purposeful sample of mothers of 20 1-5-year-old children (10 children exhibiting optimal sleep and 10 children exhibiting insufficient/fragmented sleep) attending a preschool serving a low socio-economic (SES) status metropolitan community were invited to participate in qualitative interviews. Data were coded according to a grounded theory approach and themes were identified within the optimal and suboptimal sleeper groups.

RESULTS

Mothers reported different approaches to managing electronics by optimal/suboptimal sleeper group, with mothers of optimal sleepers limiting access to electronics more than mothers in the suboptimal sleep group. Other themes of sleep health practices did not differ meaningfully between groups.

CONCLUSIONS

Maternal perspectives about early childhood sleep health were similar across optimal and suboptimal sleepers on most elements of child sleep health. Managing child sleep was contextually influenced and these results highlight the complexities of how families living in lower SES environments perceive common sleep recommendations. Thus, sleep health education efforts should be tailored to the needs and values of specific families and communities.

Post-PICU sleep efficiency and quality of life in infants and toddlers with acquired brain injury

STUDY OBJECTIVES

We aimed to investigate the use of sleep efficiency (SE) as a measure of sleep disturbance in infants and toddlers with acquired brain injury (ABI) and evaluate associations between SE and child health-related quality of life and family outcomes.

METHODS

Retrospective cohort study of 101 children ages 3-36 months who survived critical care for ABI. SE was quantified from the Brief Infant Sleep Questionnaire as a ratio of nighttime sleep to total time in bed; poor SE was defined as < 80%. Outcome measures included the Pediatric Quality of Life Inventory Core Total Score (health-related quality of life) and Family Impact Module Total Score. Spearman's correlation quantified associations between SE and outcomes. Multivariable linear regression tested association between poor SE and health-related quality of life controlling for significant covariates (age, diagnosis, comorbidities, worsening Functional Status Scale).

RESULTS

Following ABI, median SE was 91.7 (interquartile range = 83.3, 95.5). Nineteen (19%) children had poor SE (< 80%). SE correlated significantly with quality of life (Spearman's correlation = .307) and Family Impact Module (Spearman's correlation = .309; both P < .01). When controlling for covariates, poor SE significantly increased risk for lower health-related quality of life (β-coefficient = -7.0; 95% confidence interval= -13.4, -0.6).

CONCLUSIONS

One in five infants and young children with ABI have poor SE that is associated with poorer child and family health outcomes. Our study underscores the potential importance of sleep following ABI to optimize recovery and the need for additional investigation of SE in infants and young children.

CITATION

Klapp JM, Hall TA, Riley AR, Janzen D, Williams CN. Post-PICU sleep efficiency and quality of life in infants and toddlers with acquired brain injury. J Clin Sleep Med. 2024;20(1):75-83.

Sleep quality as a mediator of the relationship between screen time and negative emotions among Chinese college freshmen

College freshmen are special populations facing great challenges in adapting to the brand new environment, and their lifestyle and emotional states are worthy of attention. Especially during the COVID-19 pandemic, their screen time and prevalence of negative emotions were significantly increased, but few studies have focused on such situation of college freshmen and illustrated relevant mechanisms. Thus, based on a sample of Chinese college freshmen during the COVID-19 pandemic, the current study aimed to investigate the association between their screen time and negative emotions (depression, anxiety and stress), and further explore the mediating effects of sleep quality. Data from 2,014 college freshmen was analyzed. The screen time was self-reported by participants using predesigned questionnaires. The Pittsburgh Sleep Quality Index (PSQI) and Chinese Version of Depression Anxiety and Stress Scale-21 (DASS-21) were used to assess sleep quality and emotional states, respectively. The mediation analysis was conducted to examine the meditation effect. Results indicated that participants with negative emotions tended to have longer daily screen time and worse sleep quality, sleep quality partially mediated the association between screen time and negative emotions.The critical role of sleep quality and related intervention measures should be recognized and implemented.

Association between Children's Difficulties, Parent-Child Sleep, Parental Control, and Children's Screen Time: A Cross-Sectional Study in Japan

Children's screen time may affect their growth and development. However, differences in the impact of various psychiatric and psychological factors on children's screen time is a research gap. This study aimed to explore the differences in the influence of related factors affecting children's screen time based on their sleep, difficulties, and parental control among Japanese elementary and junior high school students. A cross-sectional survey was conducted among parents in Japan. Data on screen time duration, parent-child background, strengths and difficulties, sleep variables, and parental control types were collected from 225 households. A regression analysis revealed that high Strengths and Difficulties Questionnaire (SDQ) scores (β = 0.166, p = 0.008), sleep duration (β = -0.281, p < 0.001), and parental control (β = -0.204, p = 0.001) were significantly related to children's screen time. Additionally, it was found that parents' late bedtimes affect children's screen time by mediating children's sleep duration. This study, together with previous research, provides comprehensive insights into design interventions to decrease the screen time of children in the Japanese context.

Screen Time and Its Health Consequences in Children and Adolescents

Nowadays, children and adolescents are exposed to digital media (DM) from an early age. Therefore, specific guidelines have been published by the World Health Organization, whose aim is to limit daily screen time (ST) viewing. However, during the COVID-19 pandemic, a rise in DM use, and consequently ST viewing, was observed. More and more aspects of modern life are thought to be affected by excessive ST viewing. Accordingly, the aim of this review is to document the health effects of excessive ST viewing on children and adolescents. A narrative review was performed in searchable databases. In total, 43 original articles were considered. Excessive ST viewing was correlated with increased risk for obesity and other cardiometabolic risk factors, mental health, unhealthy dietary habits and eating disorders, and problems in development and child-parent relationships. Sleep, physical activity, eyesight, headaches, and the musculoskeletal system were negatively affected as well. However, the effect of ST was weighted by the type of media used and the way types of media were used. Other confounding factors were reported. There is evidence to suggest a negative correlation between excessive ST and youth health exists. Nevertheless, more research is needed if this correlation is to be established.

[A review of research on psychological and behavioral problems in children with autism spectrum disorder during the coronavirus disease 2019 epidemic]

Since December 2019, coronavirus disease 2019 (COVID-19) has been rapidly spreading worldwide and affecting the physical and mental health of the general population. It may have even more serious potential harm to children with autism spectrum disorder (ASD). This paper provides a literature review on the psychological and behavioral problems experienced by children with ASD during the COVID-19 epidemic, as well as the factors influencing these issues. The findings of this review can serve as a basis for clinical research on ASD children.

Potential impact of extra education on the development of executive functions within a year in preschool children: an exploratory research

Executive functions have been shown to develop through various extra classes in preschool age. But the optimal for executive functions development system of such classes has not yet been explored. The present exploratory study aimed to examine the difference in the executive functions development within a year between children attending the system of extra classes (music, choreography, art, foreign language, literacy, math, computer science, and science) twice a week for 4 h in a preschool education center and children who did not take no extra classes. There were 60 children who attended extra classes and 64 children who did not take extra classes. In each group, approximately 17% were boys. The first assessment of executive functions was performed in the penultimate year of kindergarten, when the children were 5-6 years old. The second was performed 1 year later. The executive function level was assessed using NEPSY-II subtests "Inhibition," "Statue," "Memory for Designs," "Sentences Repetition," and "Dimensional Change Card Sort." Mothers also reported about their children's attendance in extra classes, their children's screen time, the level of maternal education, and the level of family income. The study revealed that children attending the system of the extra classes showed a higher verbal working memory development within a year than the children taking no extra classes. The obtained data plays an important role for the design of further research of the topic and for the practical recommendations for parents and teachers.

Sleep Disturbances and Mental Well-Being of Preschool Children during the COVID-19 Pandemic in Mexico

COVID-19 pandemic confinement caused changes in families and children's routines worldwide. Studies conducted at the beginning of the pandemic have examined the harmful effects of these changes on mental health, including sleep disturbances. As sleep is essential for optimal childhood development, this study was designed to determine preschool-aged (3-6 years old) children's sleep parameters and mental well-being during the COVID-19 pandemic in Mexico. Using a cross-sectional design, a survey was applied to parents of preschool children, inquiring about their children's confinement status, routine changes, and electronics use. The parents responded to the Children's Sleep Habits Questionnaire and the Strengths and Difficulties Questionnaire to assess children's sleep and mental well-being. To provide objective sleep data, the children wore wrist actigraphy for seven days. Fifty-one participants completed the assessment. The children's mean age was 5.2 years, and the prevalence of sleep disturbances was 68.6%. The use of electronic tablets in the bedroom near bedtime and symptoms of mental health deterioration (i.e., emotional distress and behavioral difficulties) were associated with sleep disturbances and their severity. The COVID-19 pandemic's confinement-related routine changes greatly impacted preschool children's sleep and well-being. We recommend establishing age-tailored interventions to manage children at higher risk.

Impact of the COVID-19 pandemic on children's sleep habits: an ECHO study

BACKGROUND

Sleep in childhood is affected by behavioral, environmental, and parental factors. We propose that these factors were altered during the COVID-19 pandemic. This study investigates sleep habit changes during the pandemic in 528 children 4-12 years old in the US, leveraging data from the Environmental Influences on Child Health Outcomes (ECHO) Program.

METHODS

Data collection occurred in July 2019-March 2020 (pre-pandemic) and two pandemic periods: December 2020-April 2021 and May-August 2021. Qualitative interviews were performed in 38 participants.

RESULTS

We found no changes in sleep duration, but a shift to later sleep midpoint during the pandemic periods. There was an increase in latency at the first pandemic collection period but no increase in the frequency of bedtime resistance, and a reduced frequency of naps during the pandemic. Qualitative interviews revealed that parents prioritized routines to maintain sleep duration but were more flexible regarding timing. Children from racial/ethnic minoritized communities slept less at night, had later sleep midpoint, and napped more frequently across all collection periods, warranting in-depth investigation to examine and address root causes.

CONCLUSIONS

The COVID-19 pandemic significantly impacted children sleep, but parental knowledge of the importance of sleep might have played a significant protective role.

IMPACT

During the COVID-19 pandemic, US children changed their sleep habits, going to bed and waking up later, but their sleep duration did not change. Sleep latency was longer. Parental knowledge of sleep importance might have played a protective role. Regardless of data collection periods, children from racial/ethnic minoritized communities slept less and went to bed later. This is one of the first study on this topic in the US, including prospective pre-pandemic qualitative and quantitative data on sleep habits. Our findings highlight the pandemic long-term impact on childhood sleep. Results warrants further investigations on implications for overall childhood health.

Psychological distress mediates the connection between sleep deprivation and physical fighting in adolescents

Lack of sleep is common in adolescence, and represents an important threat to adolescents' well-being, academic commitment, and general health. It also has significant behavioral consequences through an increased likelihood of interpersonal violence. Previous studies have demonstrated an association between aggressive behavior and lack of sleep, but the psychological mediators remain completely unexplored. Grounded in the General Aggression Model, we investigated the affective pathway as one of the potential mechanisms linking lack of sleep and aggression. We hypothesized and showed that psychological distress is an intermediary phenomenon linking lack of sleep and physical aggression. Based on a school sample of 11,912 participants (median age: 14.5), we observed that 23.7% of the young people admitted having been involved in physical fighting on one or more occasions, and that 25.81% were in sleep debt when referred for medical assessment. We analyzed the relationship between sleep duration and physical fighting and the mediating link of psychological distress by performing multiple regressions in the components' paths. The results showed that the adolescents' amount of sleep appeared to be a significant predictor of physical fighting, and that this relationship was partially mediated by psychological distress. These results are consistent with the General Aggression Model, and represent the first empirical confirmation that psychological distress symptoms partially mediate the connection between lack of sleep and physical aggression.

Screen-based behaviour in children is more than meets the eye

Increased screen time (ST) in children is quickly becoming a public health concern as children are now reliant on technology for social interaction and educational development. The eye-health community has paid considerable attention to this in the recent literature, documenting it as digital eye strain. Continual close eye work and a lack of outdoor play contribute to digital eye strain and today’s myopia epidemic. This is a cause for concern for public health stakeholders insofar as it leads to sedentary, screen-based behaviour (SSB) in children. This results in a lack of physical activity and impacts both their bodies and their mental health. The potentially harmful effects of prolonged screen exposure on developing brains and bodies are likely to be unique and significant as physiological growth changes intersect with exponentially expanding e-platforms. While embracing the benefits of a highly digitalised world, we need to simultaneously mitigate the potential risks they pose to the health of growing children.

Association between Leisure Screen Time and Emotional and Behavioral Problems in Spanish Children

OBJECTIVE

To assess the relation between leisure screen time and emotional and behavioral problems in Spanish children aged 4-14 years.

STUDY DESIGN

This cross-sectional study used a representative sample of children aged 4-14 years included in the 2017 Spanish National Health Survey (n = 4073). Emotional and behavioral problems of children were assessed through the parent-report Strengths and Difficulties Questionnaire. Daily leisure screen time in minutes was categorized as 0-59, 60-119, 120-179, and ≥180. We calculated adjusted prevalence ratios (aPR) and their 95% CIs of being at risk of developing emotional and behavioral problems. Associations were adjusted for potential confounding variables.

RESULTS

Children spending 180 minutes or more of daily leisure screen time compared with children spending less than 1 hour were more likely to be at risk of developing emotional and behavioral problems: aPR_≥180: 2.19 (95% CI 1.53-3.14), emotional symptomology: aPR_≥180: 2.09 (95% CI 1.37-3.18), conduct problems aPR_≥180: 1.85 (95% CI 1.34-2.54), peer problems aPR_≥180: 1.78 (95% CI 1.15-2.75), and to behave less prosocially: aPR_≥180: 2.20 (95% CI 1.43-3.37).

CONCLUSIONS

We have found significant associations between daily leisure screen time and emotional and behavioral problems in Spanish children between 6 and 14 years of age. However, these findings should be confirmed in cohort studies, so institutions might consider including screen time as a new risk factor for children.

The Prevalence of Insufficient Sleep and Bedtime Delay Among Kindergarten Children Aged 3 to 6 Years in a Rural Area of Shanghai: A Cross-Sectional Study

Introduction: Sleep deprivation in children is a global public health problem that affects the physical and mental development of children. Bedtime delay induced by longer screen time and heavy study load is a common cause of sleep deprivation in children. However, the prevalence of insufficient sleep and bedtime delay and related influencing factors among kindergarten children is limited in Shanghai, China. Methods: In 2018, we selected 8,586 children aged 3 to 6 years and their parents in Songjiang District, Shanghai. Data was collected among parents by face-to-face questionnaire interview with signed informed consent. We defined insufficient sleep as those who slept for < 10 h in children aged 3-5 years or 9 h in children aged 6 years within 24 h, and we define bedtime delay as children with bedtime after 21:00. SAS 9.1.3 software was used to calculate the prevalence of bedtime delay and insufficient sleep, and logistic regression was used to explore potential influencing factors. Results: The prevalence of insufficient sleep and bedtime delay among children aged 3 to 6 years was 11.67 and 56.85%, respectively. The prevalence of insufficient sleep among boys was slightly higher than among girls [odds ratio (OR) = 1.18, 95% confidence interval (CI): 1.04-1.35]. With the increase of the age of children, the prevalence of insufficient sleep increased gradually (P < 0.05). The prevalence of insufficient sleep was higher among the only child in the family (OR = 1.18, 95% CI: 1.02-1.36) and those with longer hours of TV watching (OR = 109, 95% CI: 1.02-1.16). Meanwhile, the prevalence of bedtime delay was also higher among the only child in the family (OR = 1.17, 95% CI: 1.06-1.79), among those with parents accompanying for sleep (OR = 1.21, 95% CI: 1.10-1.34), and those with longer TV watching time (OR = 1.13, 95% CI: 1.07-1.18). Conclusions: Insufficient sleep and bedtime delay were prevalent in Chinese children aged 3 to 6 years, especially in boys and older children. TV watching as well as parents accompanying for sleep were associated with insufficient sleep and bedtime delay. We recommend that parents should limit the screen time of children, advocate earlier bedtime and later morning wake-up among children, as well as make their children sleep in separate beds or rooms in younger age.