Cognitive, behavioral, and functional consequences of inadequate sleep in children and adolescents

Translation and validation of the Thai Version of the Japanese Sleep Questionnaire for Preschoolers (JSQ-P)

PURPOSE

This study aimed to translate and validate the Japanese Sleep Questionnaire for Preschoolers (JSQ-P) into a Thai version and to evaluate factors associated with sleep problems in preschoolers.

METHODS

The cross-cultural adaptation of JSQ-P into Thai version of JSQ-P (TH-JSQ-P) was performed including forward translation, reconciliation, backward translation, and final approval by the original creator. Children aged 2-6 years from community and clinical settings were enrolled. The TH-JSQ-P was completed by parents of preschool children twice within 10-14 days to assess its reliability and validity. Six validity tests including face validity, content validity, structural validity, construct validity, criterion validity and predictive validity were assessed. Demographic data, Epworth sleepiness scale (ESS), medical and behavior problems, and socioeconomic status were collected for analysis.

RESULTS

A total of 2613 participants completed the TH-JSQ-P, with 1207 completing it twice to assess test-retest reliability. The TH-JSQ-P had good internal consistency reliability and test-retest ability with Cronbach's alpha value of 0.898 and intraclass correlation coefficient of 0.814. The content validity was acceptable. The ESS had correlation with sleep problems in almost all subscales except for sleep habit.

CONCLUSIONS

The TH-JSQ-P is a valid and reliable instrument for evaluating sleep problems in preschool children in Thailand. It has the potential to be extensively utilized to screen for sleep problems, thereby enabling healthcare professionals to identify them early and implement prompt management.

Do later school start times improve adolescents' sleep and substance use? A quasi-experimental study

OBJECTIVE

A later school start time policy has been recommended as a solution to adolescents' sleep deprivation. We estimated the impacts of later school start times on adolescents' sleep and substance use by leveraging a quasi-experiment in which school start time was delayed in some regions in South Korea.

METHODS

A later school start time policy was implemented in 2014 and 2015, which delayed school start times by approximately 30-90 minutes. We applied difference-in-differences and event-study designs to longitudinal data on a nationally representative cohort of adolescents from 2010 to 2015, which annually tracked sleep and substance use of 1133 adolescents from grade 7 through grade 12.

RESULTS

The adoption of a later school start time policy was initially associated with a 19-minute increase in sleep duration (95% CI, 5.52 to 32.04), driven by a delayed wake time and consistent bedtime. The policy was also associated with statistically significant reductions in monthly smoking and drinking frequencies. However, approximately a year after implementation, the observed increase in sleep duration shrank to 7  minutes (95% CI, -12.60 to 25.86) and became statistically nonsignificant. Similarly, the observed reduction in smoking and drinking was attenuated a year after.

CONCLUSIONS

Our findings suggest that policies that increase sleep in adolescents may have positive effects on health behaviors, but additional efforts may be required to sustain positive impacts over time. Physicians and education and health policymakers should consider the long-term effects of later school start times on adolescent health and well-being.

Parents' perceptions of factors influencing sleep in pediatric intensive care units: A qualitative study

PURPOSE

The purpose of this study is to explore factors influencing sleep in pediatric intensive care units as perceived by parents of critically ill children.

DESIGN AND METHODS

This descriptive qualitative study used individual semistructured interviews. Parents were recruited through purposive sampling from two pediatric intensive care units at two locations in one university hospital in Norway. Ten parents were interviewed. The interviews were analyzed using a six-phase reflexive thematic analysis.

FINDINGS

The analysis produced 17 subthemes under four main themes: environmental factors in the pediatric intensive care unit disturb children's sleep, children need trust and safety to sleep, nurses' cooperation with parents influences children's sleep, and nurses' structuring of their practices is fundamental to sleep promotion.

CONCLUSION

The parents found that the environment disturbed their children's sleep, and environmental factors were easier to control in single rooms than in multibed rooms. Children slept better when they felt safe and trusted the nurses, and parents desired more cooperation in promoting sleep for their children, which may be an essential and overlooked part of sleep promotion. Nurses varied considerably in how they prioritized sleep and structured their practices to promote sleep.

PRACTICE IMPLICATIONS

Nurses should take parents' experiences into account to better promote sleep for patients. By limiting environmental disturbances, building relationships with children to make them feel safe, including parents in sleep promotion, and prioritizing sleep in their practices, nurses could improve sleep quality and limit the consequences of sleep disturbance.

Factors contributing to the diagnosis and onset prediction of perennial allergic rhinitis in high-risk children: A sub-analysis of the CHIBA study

BACKGROUND

This study aimed to clarify the diagnostic and predictive factors for perennial allergic rhinitis (PAR) onset in children by analyzing the results of the Chiba High-risk Birth Cohort for Allergy study, which examined newborns with a family history of allergies.

METHODS

Overall, 306 pregnant women were recruited. Their newborns were examined by otolaryngologists and pediatric allergists at 1, 2, and 5 years of age. Participants with clinical and laboratory data available at all consultation points were considered eligible.

RESULTS

Among 187 eligible participants, the prevalence rates of PAR were 2.1%, 4.3%, and 24.1% at 1, 2, and 5 years of age, respectively. AR-specific nasal local findings and eosinophils in nasal smear were observed in a substantial number of patients with PAR at 1 and 2 years of age. Factors present up to 2 years of age that were associated with PAR onset at 5 years of age, in descending order, were as follows: sensitization to house dust mites (HDM), nasal eosinophilia, and sensitization to cat dander. In 44 cases with HDM sensitization, nasal eosinophilia up to 2 years of age achieved a sensitivity of 76.0% and a specificity of 73.7% for predicting PAR onset at 5 years.

CONCLUSIONS

Rhinitis findings and nasal eosinophilia are useful auxiliary diagnostic items for pediatric PAR. Sensitization to HDM and nasal eosinophilia were the most influential factors associated with future PAR onset. A combination of these factors may facilitate the prediction of PAR onset.

Sleep and mental health during the COVID-19 pandemic: findings from an online questionnaire survey in China

Introduction

The online study investigated the sleep, psychological conditions, and risk factors during the wave of transmission of COVID-19 since December 7, 2022.

Methods

We distributed questionnaires through networking mediums to residents to gather information about COVID-19 infection, sleep, and mental status.

Results

During the extraordinary period in China, 91.9% of 1094 participants claimed to be infected with COVID-19, 36.8% reported poor sleep quality, 75.9% reported anxiety, and 65.5% reported depression. In retrospect, people have experienced lower sleep quality, longer sleep latency, enhanced rising time, and decreased sleep efficiency after the infection wave. After adjusting confounding factors, the elderly, women, urban residents, people with comorbidity, anxiety, depression, stress state, and COVID-19 infection have high risks for sleep disorders during the period.

Discussion

The survey indicates that sleep disturbance caused by COVID-19 involves multiple dimensions, such as physiology, psychology, and society. The COVID-19 infection-related sleep problem should be taken seriously. Apart from conventional treatment, psychological issues of insomnia can not be ignored.

Greater social jetlag predicts poorer NIH Toolbox crystallized cognitive and academic performance in the Adolescent Brain Cognitive Development (ABCD) study

Academic performance plays a crucial role in long-term educational attainment and occupational function. Chronotype refers to an individual's daily tendencies for times for waking, activity, and sleep. Social jetlag reflects the mismatch between an individual's chronotype and their social schedule. Because school typically starts early in the morning, later chronotype is often associated with daytime sleepiness, insufficient sleep, and poor academic performance. However, the relationship between academic performance, chronotype, and social jetlag has not been extensively examined in large samples like the Adolescent Brain Cognitive Development (ABCD) study. We hypothesized that greater social jetlag would predict poorer cognitive and academic performance. Year 2 (ages 11-14) cross-sectional data from the ABCD cohort (n = 6,890 adolescents) were used to evaluate academic performance (i.e. self-reported past year grades), NIH Toolbox cognitive performance measures, chronotype, and social jetlag from the Munich Chronotype Questionnaire. We found that later chronotype and greater social jetlag predicted poorer cognitive and academic performance with small effect sizes. Our findings emphasize the importance of individual differences in chronotype and social jetlag when designing class schedules, as aligning school activities with student optimal sleep-wake times may contribute to improved academic performance.

Sleep disturbances in children and adolescents after kidney transplantation

BACKGROUND

Disturbances of sleep are prevalent among children with chronic kidney disease. However, the aetiology of sleep disorders in children particularly after kidney transplantation is not clear. We sought to ascertain the prevalence and type of sleep disturbances in paediatric kidney transplant recipients and to identify predictors of sleep disturbances in this population.

METHODS

Caregivers of kidney transplant recipients completed online questionnaires about their child's sleep. The questionnaires utilised were the Sleep Disturbance Scale for Children (SDSC), the Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD), questions about sleep hygiene, and questions about restless leg syndrome. Demographic and clinical details were collected from medical records.

RESULTS

Thirty-five children were included in the study, with a median (IQR) age of 14.1 years (9.5-16.1) and median years (IQR) since transplant of 3.7 (0.7-8.7) years, and 72.0% were identified to have at least one category of sleep disturbance according to scores on the SDSC. The most common sleep disturbances reported were disorders of initiating and maintaining sleep (DIMS) (40.0%) and disorders of excessive somnolence (DOES) (31.4%). Statistically significant predictors of sleep disturbances include low estimated glomerular filtration rate and increased age. Among children who screened positive for DIMS and DOES, the majority indicated use of electronic devices in 1 h before bed.

CONCLUSIONS

A high prevalence of sleep disturbances has been identified in children after kidney transplants, and some risk factors may be modifiable. Further studies are required to understand whether there are other readily modifiable predictors of sleep disturbances.

Urbanisation negatively impacts sleep health and mood in adolescents: a comparative study of female students from city and rural schools of North India

This study investigated the impact of social settings on sleep, physical and mental health in female adolescents of North India (latitude 29.5 oN; longitude 77.5 oE). Using a battery of questionnaires, we compared the chronotype, sleep-wake pattern, sleep health (e.g. sleep quality, daytime sleepiness and fatigue) and mood (via depression, anxiety and stress symptoms) in female students (age 14-18 years) from rural (N = 719) and urban (N = 1033) schools separated by about 35 km, but families had almost similar socio-demographic details. The morning type was prevalent amongst rural, whilst the evening type was prevalent amongst urban students who also had access to smart phones, suggesting a possible greater use of the internet. There were greater negative sleep effects, daytime sleepiness, overall poor sleep quality, higher fatigue and anxiety levels in urban than the rural cohort. Interestingly, these measures also differed between school days and free days, suggesting an impact of the conflict between internal biological and social timings (= social jet lag). We also found a significant relationship between chronotype, internet addiction, mood-related parameters and measures of sleep health. Overall, these results suggest a possible impact of social settings on sleep health and mood-related behaviours in female adolescents.

Association between adverse childhood experiences and sleep quality, emotional and behavioral problems and academic achievement of children and adolescents

The impact of adverse childhood experiences (ACEs) on adult health has been extensively examined, but the association between ACEs and sleep, emotion, behavior and academic outcomes of children and adolescents is not well known. A total of 6363 primary and middle school students were included to examine the effect of ACEs on sleep quality, emotional and behavioral problems and academic achievement and further explore the mediation role of sleep quality and emotional and behavioral problems. Children and adolescents with ACE exposure had 1.37 times risk of poor sleep quality (adjusted odds ratio [OR] = 1.37, 95% confidence interval [CI]: 1.21-1.55), 1.91 times risk of emotional and behavioral problems (adjusted OR = 1.91, 95%CI: 1.69-2.15) and 1.21 times risk of self-reported lower academic achievement (adjusted OR = 1.21, 95%CI: 1.08-1.36). Most types of ACEs were significantly associated with poor sleep quality, emotional and behavioral problems and lower academic achievement. There were dose-response relationships between cumulative ACE exposure and risk of poor sleep quality, emotional and behavioral problems, and lower academic achievement. Sleep quality and emotional and behavioral performance mediated 45.9% of the effect of ACEs exposure on math scores and 15.2% of the effect of ACEs exposure on English scores. Early detection and prevention of ACEs among children and adolescents are urgent and essential, and targeted interventions for sleep and emotional and behavioral performance as well as early educational interventions are recommended for children with ACEs exposure.

Delayed melatonin circadian timing, lower melatonin output, and sleep disruptions in myopic, or short-sighted, children

STUDY OBJECTIVES

This study investigated the differences in melatonin circadian timing and output, sleep characteristics, and cognitive function in myopic and non-myopic (or emmetropic) children, aged 8-15 years.

METHODS

Twenty-six myopes (refractive error [mean ± standard error mean] -2.06 ± 0.23 diopters) and 19 emmetropes (-0.06 ± 0.04 diopters), aged 11.74 ± 2.31 years were recruited. Circadian timing was assessed using salivary dim-light melatonin onset (DLMO), collected half-hourly for 7 hours, beginning 5 hours before and finishing 2 hours after individual average sleep onset in a sleep laboratory. Nocturnal melatonin output was assessed via aMT6s levels from urine voids collected from 05:30 pm to 8:00 am the following morning. Actigraphy-derived objective sleep timing were acquired for a week prior to the sleep laboratory visit. Cognitive assessments of sustained attention (using psychomotor vigilance task [PVT]) and working memory (using digit spans) were performed on the night of sleep laboratory.

RESULTS

Myopic children (9:07 pm ± 14 minutes) exhibited a DLMO phase-delay of 1 hour 8 minutes compared to emmetropes (7:59 pm ± 13 minutes), p = 0.002. aMT6s melatonin levels were significantly lower among myopes (18.70 ± 2.38) than emmetropes (32.35 ± 6.93, p = 0.001). Myopes also exhibited significantly delayed sleep onset, delayed wake-up time, poor and reduced sleep, and more evening-type diurnal preference than emmetropes (all p < 0.05). Finally, myopes showed a slower reaction time in the PVT (p < 0.05), but not digit span tasks at night.

CONCLUSIONS

These findings suggest a potential association between circadian rhythm dysfunction and myopia in children.

The Feasibility of Screening for Sleep Problems in Early Childhood Education Programs

OBJECTIVES

Assess the feasibility and staff experience of screening for behavioral sleep problems (BSP) and sleep disordered breathing (SDB) in early childhood education (ECE) settings; examine BSP/SDB prevalence and caregivers' knowledge/attitudes, perception of child sleep problems, and sleep health engagement in this sample.

METHOD

Eight staff representatives from four ECE sites involved with sleep problem screening procedures within a larger RCT on ECE sleep health, discussed their experiences in a focus group; transcript content reviewed. A random subset of caregiver-child dyads (n = 59) from the four ECE sites completed sleep problem measures (BSP: Children's Sleep Habits Questionnaire, Short form [SF-CSHQ], Tayside Children's Sleep Questionnaire [TCSQ-sleep disturbance and difficulty] and SDB: Pediatric Sleep Questionnaire [PSQ], in addition to RCT measures (Parent Knowledge/Attitude/Self-efficacy/Beliefs survey and sleep health goals). Caregiver sleep health engagement was measured by the sleep health goals set.

RESULTS

ECE staff reported sleep problem screening as self-explanatory and doable but sometimes administratively burdensome. BSPs were identified in 44% (SF-CSHQ) to 63% (TCSQ-sleep disturbance) of children; SDBs in 13%. Only 11% of caregivers endorsed their child having a sleep "difficulty" (TCSQ). Sleep health goals were set by 85% of caregivers; 63% employed educational materials' language.

CONCLUSION

Sleep problem screening in ECE is feasible, and problems are elicited. While caregivers readily engage in setting healthy sleep goals, few endorse sleep as difficult. ECE education could improve caregiver understanding/recognition of sleep problems.

Common Childhood Sleep Problems and Disorders

BACKGROUND

Sleep insufficiency and disturbances affect the physical, cognitive, and emotional well-being of children.

OBJECTIVE

To perform a narrative review on common sleep problems and disorders encountered in primary care for children and adolescents.

METHODS

A search of English literature in the Pubmed and Google Scholar databases published from 1 January 2000 till 31 October 2021 was conducted with the keywords "sleep problem" or "sleep disorder" and "child" or "adolescent". Findings in the relevant articles and cross-references were compiled.

RESULTS

Sleep duration and habits of children vary widely across countries with different cultural backgrounds. There is robust evidence to support the promotion of positive bedtime routines and sleep hygiene as prevention and management of sleep problems. 15-70% of parents reported their children having sleep problems or disturbances. Common sleep complaints include difficulty in initiation or maintenance of sleep, abnormal behaviors or movements, snoring or abnormal breathing, and excessive daytime sleepiness. Comprehensive sleep history and a sleep diary are the first steps for evaluation. Home video and actigraphy may be used as preliminary tools to confirm the history. Referrals to a sleep specialist for polysomnography and other tests are needed, if suspecting specific sleep disorders, such as obstructive sleep apnea and narcolepsy, needs timely intervention. Common sleep disorders in different age groups encountered in primary care are reviewed with clinical features, indications for evaluation, and treatment options summarized.

CONCLUSION

Screening for sleep problems shall be an integral part of each child's health care visit. It is important to evaluate the impact of common sleep problems and identify specific sleep disorders for early intervention to prevent long-term adverse outcomes.

Associations of deep sleep and obstructive sleep apnea with family relationships, life satisfaction, and physical stress experience in children: a caregiver perspective

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) and poor quality of sleep negatively impacts health-related quality of life in adults, but few studies have evaluated the association between sleep disturbance (eg, OSA, inadequate sleep) and health-related quality of life domains (eg, family relations, life satisfaction) in children.

METHODS

Children ages 8-17 years referred to a sleep center for routine polysomnography from April 2022 to August 2022 were approached to participate in the study, and children visiting the department of pediatrics for their wellness visit were recruited for comparisons. Statistical analysis was conducted using R 3.6.0.

RESULTS

Ninety-nine children were recruited from the sleep clinic, and 23 children were recruited from the primary care clinic. Of these children, 62 were diagnosed with obstructive sleep apnea (31 mild, 12 moderate, 19 severe), and 37 did not meet criteria for a diagnosis. Health-related quality of life domains did not differ across OSA severity levels. Children in general had lower life satisfaction and higher physical stress experience compared to children visiting for their wellness examination (well-child visitors, P = .05 and P = .005, respectively). Children with severe OSA had significantly lower life satisfaction and significantly higher physical stress experience when compared with well-child visitors (P = .008 and P = .009, respectively). Correlation analysis showed that N3 (deep) sleep was positively associated with family relations and life satisfaction, while it was negatively associated with anger.

CONCLUSIONS

Based on caregiver response, N3 sleep is positively associated with family relations and life satisfaction and negatively associated with anger. Severe OSA is associated with lower life satisfaction and higher physical stress experience.

CITATION

Bhushan B, Zee PC, Grandner MA, et al. Associations of deep sleep and obstructive sleep apnea with family relationships, life satisfaction, and physical stress experience in children: a caregiver perspective. J Clin Sleep Med. 2023;19(12):2087-2095.

Longitudinal sleep multi-trajectories from age 1 to 5.5 years and their early correlates: results from the Étude Longitudinale Française depuis l'Enfance birth cohort study

STUDY OBJECTIVES

To identify sleep multi-trajectories in children from age 1 to 5.5 years and their early correlates.

METHODS

We collected early family, maternal, and child characteristics, including children's nighttime sleep duration (NSD) and daytime sleep duration (DSD), night waking (NW), and sleep-onset difficulties (SOD), by parental phone interviews at age 2 months and 1-, 2-, 3.5-, and 5.5 years. Group-based multi-trajectory modeling identified sleep multi-trajectory groups. Multinomial logistic regression assessed associations with early factors.

RESULTS

We identified five distinct sleep multi-trajectory groups for NSD, DSD, NW, and SOD in 9273 included children. The "Good sleepers" (31.6%) and "Long sleepers" (31.0%) groups had low NW and SOD prevalence and shorter NSD but longer DSD in "Good sleepers" than in "Long sleepers." The "Good sleepers but few SOD" group (10.3%) had long NSD and DSD but a SOD peak at age 3.5 years; the "Improving NW and SOD" group (9.6%) showed short but rapidly increasing NSD to a plateau and high but decreasing NW and SOD; the "Persistent NW and SOD" group (17.5%) had persistent high NW and SOD. Maternal depression during pregnancy and sleep habits at age 1 (e.g. parental presence or feeding to fall asleep, sleeping at least part of the night away from own bed) were common risk factors associated with the most disordered sleep multi-trajectory groups.

CONCLUSIONS

We identified distinct sleep multi-trajectory groups and early life-associated factors in preschoolers. Most of the factors associated with the most sleep-disordered multi-trajectory groups are likely modifiable and provide clues for early prevention interventions.

Short Sleep Duration in School-Age Children: Differential Factors on Weekdays and Weekends

OBJECTIVES

To quantify school-age children's sleep and parent-associated factors on weekdays and weekends in Singapore, and investigate school-related and parent-related factors associated with short sleep.

METHODS

In an online survey, 251 parents with a child aged 7-12 y in Singapore reported their child's sleep duration and school start time. Parent-related factors including sleep hygiene (e.g., parent-set bedtime), sleep priority (the amount of sleep respondents allowed their children to trade for other activities), and both parents' sleep durations, were also reported.

RESULTS

The prevalence of short sleep among the children was 64.5% on weekdays and 19.5% on weekends. Children's sleep duration increased from 8.42 h on weekdays to 9.45 h on weekends (p < .001). Relative to weekdays, on weekends, parents showed similar increases in sleep durations (p < .001), imposed poorer sleep hygiene on their children (reduced likelihood of setting bedtimes and increased pre-bedtime electronic device use; p < .001), and allowed their children to trade more sleep for interacting with family and friends, social media, gaming, and TV / videos (p < .001). Shorter sleep duration in children was significantly associated with earlier school start time (B = 0.80, p = .02) and poorer sleep hygiene on weekdays (B = 0.16, p < .001), but lower sleep priority (B = 0.05, p = .002) and shorter parental sleep duration on weekends (maternal: B = 0.18, p < .001, paternal: B = 0.17, p = .002).

CONCLUSIONS

Delaying school start times may be effective in increasing school-age children's sleep duration on weekdays, while family-based interventions designed to enhance sleep hygiene, priority of sleep over other activities, and parents' sleep durations can benefit children's sleep duration on both weekdays and weekends.

Attention Deficit Hyperactivity Disorder Misdiagnosis: Why Medical Evaluation Should Be a Part of ADHD Assessment

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that interferes with multiple aspects of daily functioning and is associated with impairments in several domains. It may affect academic, educational, vocational, social, emotional, interpersonal, and health domains, and worsen risks to health outcomes.

OBJECTIVE

To identify and discuss medical conditions that commonly present with symptoms resembling ADHD.

METHOD

This review is selective and not systematic. It is conducted through a focused literature search through PubMed, Google Scholar, and EMBASE. Search term included "ADHD misdiagnosis", "medical conditions with ADHD like symptoms", "ADHD AND medical problems".

EXCLUSION

giftedness, high IQ, and any article that does not list medical conditions. The limits applied were the following: the work must have been published in the past 20 years, be on humans, and be in the English language.

RESULTS

There are several medical conditions that can be misdiagnosed as ADHD and may show a similar presentation to ADHD, particularly with inattentive symptoms. Examples include, but are not limited to, absence seizure disorder, diabetes, thyroid dysfunction, sleep deprivation, post-concussion states, inflammatory bowel disease, iron deficiency states and anemia, and disordered breathing.

CONCLUSIONS

Our review suggests that a thorough medical evaluation should be conducted prior to the diagnosis of ADHD. Allied health professionals and psychologists who diagnose ADHD should seek medical clearance from a physician prior to making the ADHD diagnosis in order to reduce misdiagnosis rates and improve patient outcomes. ADHD diagnosis should follow guidelines and be carried out under a systematic standardized approach. A full medical evaluation should be conducted to assess for medical conditions that may look like ADHD or be associated with ADHD.

Morning perception of sleep, stress, and mood, and its relationship with overnight physiological sleep: findings from the National Consortium on Alcohol and Neurodevelopment in Adolescence (NCANDA) study

This cross-sectional study investigated objective-subjective sleep discrepancies and the physiological basis for morning perceptions of sleep, mood, and readiness, in adolescents. Data collected during a single in-laboratory polysomnographic assessment from 137 healthy adolescents (61 girls; age range: 12-21 years) in the United States National Consortium on Alcohol and Neurodevelopment in Adolescence (NCANDA) study were analysed. Upon awakening, participants completed questionnaires assessing sleep quality, mood, and readiness. We evaluated the relationship between overnight polysomnographic, electroencephalographic, sleep autonomic nervous system functioning measures, and next morning self-reported indices. Results showed that older adolescents reported more awakenings, yet they perceived their sleep to be deeper and less restless than younger adolescents. Prediction models including sleep physiology measures (polysomnographic, electroencephalographic, and sleep autonomic nervous system) explained between 3% and 29% of morning sleep perception, mood, and readiness indices. The subjective experience of sleep is a complex phenomenon with multiple components. Distinct physiological sleep processes contribute to the morning perception of sleep and related measures of mood and readiness. More than 70% of the variance (based on a single observation per person) in the perception of sleep, mood, and morning readiness is not explained by overnight sleep-related physiological measures, suggesting that other factors are important for the subjective sleep experience.

Comparing the Driving Skills of Adolescents with Obstructive Sleep Apnea to Healthy Controls: The Results of a Case-Controlled Observational Study

Auto crashes are a leading cause of death and injury among adolescents. Untreated obstructive sleep apnea (OSA) can cause sleepiness and inattention, which could negatively impact novice drivers, but OSA-related studies have focused on older drivers. This study used a driving simulator to examine whether licensed 16-19-year-old adolescents with OSA have diminished driving skills. Twenty-one adolescents with OSA and twenty-eight without OSA (both confirmed using polysomnography) completed two randomly ordered driving trials in a simulator (with induced distractions versus without). A mixed ANOVA examined the between-subjects effect of the OSA group, the within-subjects effect of the distraction condition, and the group-by-condition interaction effect on the ability to maintain lane position and the frequency of extended eye glances away from the roadway. T-tests were also used to examine group differences in reported sleepiness and inattention during daily life. The distraction task increased extended off-road glances and difficulties maintaining lane position (p < 0.001). However, adolescents with OSA did not display worse eye glance or lane position than controls and there were no significant group-by-condition interactions. Although the groups differed on polysomonographic features, there were also no significant differences in reported sleepiness or inattention. The distraction task negatively impacted both groups of adolescent drivers, but those with OSA did not fare differentially worse. Most adolescents in our study had mild OSA (median obstructive apnea-hypopnea index = 4.4), the most common form in the community. It remains possible that youth with more severe OSA would show increased driving impairment.

What is the Sleep Pattern of Infants and Toddlers in the Iranian Population? An Epidemiological Study

Objective  To identify sleep patterns and sleep behaviors in a group of infants and toddlers (0 to 36 months) in Iran. Methods  Parents and caregivers of 602 infants and toddlers in Iran completed a Persian translation of the Brief Infant Sleep Questionnaire. To assess the differences among the age groups, non-parametric statistical approaches such as the Kruskal-Wallis and chi-square tests were employed. Results  The infants and toddlers went to bed relatively late (22:30), and the median night awakening was 2 times (20 min). They most likely slept in the same room with their parents (55.5%), and commonly in the same bed (18.9%). They slept a median of 11.50 hours per day. A significant percentage of the parents felt that their child had moderate or severe sleep problems (22.4%). These children's sleep patterns had significant developmental changes, including decreased daytime sleep, reduced overall sleep, and increased sleep consolidation (reduced number and duration of night awakenings and increased overall sleep duration). The parents commonly used holding-and-rocking and bottle/breastfeeding to initiate infants' sleep and bottle/breastfeeding to resume their infants' sleep. Discussion  These findings provide reference data for professionals to assess sleep in children under 3 years of age and also supply knowledge about common parenting practices related to a child's sleep. Cross-cultural comparisons using the findings can offer new insights into the practices and behaviors of parents concerning infant and toddler sleep.

Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing

STUDY OBJECTIVES

Children with snoring and mild sleep-disordered breathing may be at increased risk for neurocognitive deficits despite few obstructive events. We hypothesized that actigraphy-based sleep duration and continuity associate with neurobehavioral functioning and explored whether these associations vary by demographic and socioeconomic factors.

METHODS

298 children enrolled in the Pediatric Adenotonsillectomy Trial, ages 3 to 12.9 years, 47.3% from racial or ethnic minority groups, with habitual snoring and an apnea-hypopnea index < 3 were studied with actigraphy (mean 7.5 ± 1.4 days) and completed a computerized vigilance task (Go-No-Go) and a test of fine motor control (9-Hole Pegboard). Caregivers completed the Behavior Rating Inventory of Executive Function. Regression analyses evaluated associations between sleep exposures (24-hour and nocturnal sleep duration, sleep fragmentation index, sleep efficiency) with the Behavior Rating Inventory of Executive Function Global Executive Composite index, pegboard completion time (fine motor control), and vigilance (d prime on the Go-No-Go), adjusting for demographic factors and study design measures.

RESULTS

Longer sleep duration, higher sleep efficiency, and lower sleep fragmentation were associated with better executive function; each additional hour of sleep over 24 hours associated with more than a 3-point improvement in executive function (P = .002). Longer nocturnal sleep (P = .02) and less sleep fragmentation (P = .001) were associated with better fine motor control. Stronger associations were observed for boys and children less than 6 years old.

CONCLUSIONS

Sleep quantity and continuity are associated with neurocognitive functioning in children with mild sleep-disordered breathing, supporting efforts to target these sleep health parameters as part of interventions for reducing neurobehavioral morbidity.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Pediatric Adenotonsillectomy for Snoring (PATS); URL: https://clinicaltrials.gov/ct2/show/NCT02562040; Identifier: NCT02562040.

CITATION

Robinson KA, Wei Z, Radcliffe J, et al. Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing. J Clin Sleep Med. 2023;19(9):1595-1603.

Pediatric sleep: current knowledge, gaps, and opportunities for the future

This White Paper addresses the current gaps in knowledge, as well as opportunities for future studies in pediatric sleep. The Sleep Research Society's Pipeline Development Committee assembled a panel of experts tasked to provide information to those interested in learning more about the field of pediatric sleep, including trainees. We cover the scope of pediatric sleep, including epidemiological studies and the development of sleep and circadian rhythms in early childhood and adolescence. Additionally, we discuss current knowledge of insufficient sleep and circadian disruption, addressing the neuropsychological impact (affective functioning) and cardiometabolic consequences. A significant portion of this White Paper explores pediatric sleep disorders (including circadian rhythm disorders, insomnia, restless leg and periodic limb movement disorder, narcolepsy, and sleep apnea), as well as sleep and neurodevelopment disorders (e.g. autism and attention deficit hyperactivity disorder). Finally, we end with a discussion on sleep and public health policy. Although we have made strides in our knowledge of pediatric sleep, it is imperative that we address the gaps to the best of our knowledge and the pitfalls of our methodologies. For example, more work needs to be done to assess pediatric sleep using objective methodologies (i.e. actigraphy and polysomnography), to explore sleep disparities, to improve accessibility to evidence-based treatments, and to identify potential risks and protective markers of disorders in children. Expanding trainee exposure to pediatric sleep and elucidating future directions for study will significantly improve the future of the field.

School start time delays and high school educational outcomes: Evidence from the START/LEARN study

INTRODUCTION

Delaying high school start times extends adolescents' nightly sleep, but it is less clear how it affects educational outcomes. We expect links between school start time delays and academic performance because getting enough sleep is a key input to the cognitive, health, and behavioral factors necessary for educational success. Thus, we evaluated how educational outcomes changed in the 2 years following a school start time delay.

METHODS

We analyzed 2153 adolescents (51% male, 49% female; mean age 15 at baseline) from START/LEARN, a cohort study of high school students in the Minneapolis-St. Paul, MN, USA metropolitan area. Adolescents experienced either a school start time delay ("policy change schools") or consistently early school start times ("comparison schools"). We compared patterns of late arrivals, absences, behavior referrals, and grade point average (GPA) 1 year before (baseline, 2015-2016) and 2 years after (follow-up 1, 2016-2017 and follow-up 2, 2017-2018) the policy change using a difference-in-differences analysis.

RESULTS

A school start time delay of 50-65 min led to three fewer late arrivals, one fewer absence, a 14% lower probability of behavior referral, and 0.07-0.17 higher GPA in policy change schools versus comparison schools. Effects were larger in the 2nd year of follow-up than in the 1st year of follow-up, and differences in absences and GPA emerged in the second year of follow-up only.

CONCLUSIONS

Delaying high school start times is a promising policy intervention not only for improving sleep and health but for improving adolescents' performance in school.

Racial and ethnic disparities in insufficient sleep among US in infants and preschoolers

OBJECTIVE

To examine racial and ethnic disparities and associated factors of insufficient sleep among children from infancy to preschool-aged.

METHODS

We analyzed parent-reported data on US children ages 4 months-5 years (n = 13,975) from the 2018 and 2019 National Survey of Children's Health. Children who slept less than the age-specific minimum hours recommended by the American Academy of Sleep Medicine were classified as having insufficient sleep. Logistic regression was used to estimate unadjusted and adjusted odds ratios (AOR).

RESULTS

An estimated 34.3% of children from infancy to preschool-aged experienced insufficient sleep. Socioeconomic factors (poverty [AOR] = 1.5, parents' education level [AORs] from 1.3 to 1.5); parent-child interaction variables (AORs from 1.4 to 1.6); breast feeding status (AOR = 1.5); family structure (AORs from 1.5 to 4.4); and weeknight bedtime regularity (AORs from 1.3 to 3.0) were significantly associated with having insufficient sleep. Non-Hispanic Black (OR = 3.2) and Hispanic children (OR = 1.6) had significantly higher odds of insufficient sleep compared to non-Hispanic White children. Racial and ethnic disparities in insufficient sleep between non-Hispanic White children and Hispanic children were largely attenuated by adjusting for social economic factors. However, the difference in insufficient sleep between non-Hispanic Black and non-Hispanic White children remains (AOR = 1.6) after adjusting socioeconomic and other factors.

CONCLUSIONS

More than one-third of the sample reported insufficient sleep. After adjusting for socio-demographic variables, racial disparities in insufficient sleep decreased but persistent disparities existed. Further research is warranted to examine other factors and develop interventions to address multilevel factors and improve sleep health among racial and ethnic minority group children.

Sleep-related items on the school-age CBCL and the PROMIS sleep disturbance 4-item short-form: A psychometric comparison from the Environmental Influences on Child Health Outcomes (ECHO) program

The Child Behavior Checklist (CBCL) parent-report school-age form, a broad instrument widely used to evaluate youth's emotional and behavioral functioning, includes seven sleep-related items. These items are not an official subscale of the CBCL, but researchers have used them as a measure of general sleep problems. The primary objective of the present study was to evaluate the construct validity of the CBCL sleep items with a validated measure of sleep disturbance, the Patient-Reported Outcomes Measurement Information System Parent Proxy Short Form-Sleep Disturbance 4a (PSD4a). To do so, we used coadministered data on the two measures from 953 participants ages 5-18 years in the National Institutes of Health Environmental influences on Child Health Outcomes research program. Exploratory factor analysis (EFA) revealed two CBCL items were strictly jointly unidimensional with the PSD4a. To help prevent floor effects, we conducted further analyses that revealed three additional CBCL items could be included as an ad hoc measure of sleep disturbance. However, the PSD4a remains a psychometrically superior measure of child sleep disturbance. Researchers using these CBCL items to measure child sleep disturbance should account for these psychometric issues in their analysis and/or interpretation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Self-reported quantity and quality of sleep in children and adolescents with a chronic condition compared to healthy controls

To assess self-reported quantity and quality of sleep in Dutch children with a chronic condition compared to healthy controls and to the recommended hours of sleep for youth. Sleep quantity and quality were analyzed in children with a chronic condition (cystic fibrosis, chronic kidney disease, congenital heart disease, (auto-)immune disease, and medically unexplained symptoms (MUS); n = 291; 15 ± 3.1 years, 63% female. A subset of 171 children with a chronic condition were matched to healthy controls using Propensity Score matching, based on age and sex, ratio 1:4. Self-reported sleep quantity and quality were assessed with established questionnaires. Children with MUS were analyzed separately to distinguish between chronic conditions with and without an identified pathophysiological cause. Generally, children with a chronic condition met the recommended amount of sleep, however 22% reported poor sleep quality. No significant differences in sleep quantity and quality were found between the diagnosis groups. Children with a chronic condition and with MUS slept significantly more than healthy controls at ages 13, 15, and 16. Both at primary and secondary school, poor sleep quality was least frequent reported in children with a chronic condition and most often reported in children with MUS.  Conclusion: Overall, children with chronic conditions, including MUS, met the recommended hours of sleep for youth, and slept more than healthy controls. However, it is important to obtain a better understanding of why a substantial subset of children with chronic conditions, mostly children with MUS, still perceived their sleep quality as poor. What is Known: • According to the Consensus statement of the American Academy of Sleep medicine, typically developing children (6 to 12 years) should sleep 9 to 12 h per night, and adolescents (13 to 18 years) should sleep 8 to 10 h per night. • Literature on the optimal quantity and quality of sleep in children with a chronic condition is very limited. What is New: Our findings are important and provide novel insights: • In general, children with a chronic condition sleep according to the recommended hours of sleep. • A substantial subset of children with chronic conditions, perceived their sleep quality as poor. Although this was reported mostly by children with medically unexplained symptoms (MUS), the found poor sleep quality was independent of specific diagnosis.

The Role of Supplements and Over-the-Counter Products to Improve Sleep in Children: A Systematic Review

The sleep-wake cycle is a complex multifactorial process involving several neurotransmitters, including acetylcholine, norepinephrine, serotonin, histamine, dopamine, orexin and GABA, that can be, in turn, regulated by different nutrients involved in their metabolic pathways. Although good sleep quality in children has been proven to be a key factor for optimal cognitive, physical and psychological development, a significant and ever-increasing percentage of the pediatric population suffers from sleep disorders. In children, behavioral interventions along with supplements are recommended as the first line treatment. This systematic review was conducted, according to the PRISMA guidelines, with the purpose of assessing the principal nutrients involved in the pathways of sleep-regulating neurotransmitters in children and adolescents. Our focus was the utilization of over the counter (OTC) products, specifically iron, hydroxytryptophan, theanine and antihistamines in the management of different pediatric sleep disorders with the intention of providing a practical guide for the clinician.

Psychosocial determinants of sleep difficulties in adolescence: the role of perceived support from family, peers, and school in an Italian HBSC sample

The present study explores the concurrent contribution to sleep problems of individual-related, family-related, and school-related factors in adolescence. Gathering from the Italian 2018 Health Behavior in School-Aged Children (HBSC) data collection, we used hierarchical logistic regression on a sample of 3397 adolescents (51% females, Mage = 13.99, SD = 1.62) to explore the contribution to sleep problems of the individual (Model 1: alcohol use, smoking, screen time, physical activity), familial (Model 2: parental communication, parental support), and school-related (Model 3: peer support, schoolmates/students support, teacher support and school pressure) variables. 28.3 percent of adolescents reported having sleep difficulties. Overall, Model 3 significantly improved over Model 2 and Model 1. Data showed that increasing smoking (OR = 1.11; 95% CI: 1.03-1.20) and screen time (OR = 1.05; 95% CI: 1.02-1.08) were associated with sleep difficulties but not alcohol use and physical activity. Also, impaired communication with both parents and increasing parental support (OR = 0.84; 95% CI: 0.78-0.90) were associated with decreased odds of sleep problems. Finally, both increases in school pressure (OR = 1.40; 95% CI: 1.26-1.56) and lack of student support (OR = 1.25; 95% CI: 1.10-1.42) were associated with a higher likelihood of sleep problems, while peer support and teacher support were not.   Conclusion: Our findings highlight the importance of an integrated approach to the study of sleep difficulties in adolescence that includes specific psychosocial contributors such as the quality of parental communication and perceived parental support and considers the quality of the day-to-day relationship with schoolmates and the school level of demands. What is Known: • Adolescents' are at-risk of more significant sleep difficulties, and recent literature highlights the importance of an integrated approach to understanding this phenomenon, including biological, psychosocial, and contextual factors. • The literature lacks findings that consider the concurrent contribution of individual and psychosocial factors to sleep difficulties in adolescence. What is New: • The quality of parental communication and perceived parental support, as expressions of adult figures' emotional and behavioural availability in the adolescent's life, are significant determinants of sleep difficulties. • The quality of day-to-day relationships with schoolmates and the school level of demands contribute to adolescent sleep problems.

Sleep Well, Study Well: A Systematic Review of Longitudinal Studies on the Interplay between Sleep and School Experience in Adolescence

Adolescents spend most of their daily time in school and performing school-related activities. Different aspects of their school experiences, such as school performance, psychological factors related to school, and structural factors, consistently impact adolescents' health and are likely to be intertwined with their sleep (i.e., quantity and quality, sleep disturbances). This systematic review aimed to comprehensively summarize the reciprocal and longitudinal associations between adolescents' sleep and multiple aspects of their school experience. Using multiple search strategies and applying a two-step selection process, 25 journal articles matched the eligibility criteria and were thus included in the review. The results highlighted the contribution of poor sleep quality and sleep disturbances in predicting longitudinal school experiences-related outcomes (i.e., decreasing school engagement and performance, and increasing school-related burnout, absenteeism, and bullying). At the same time, the results showed how experiences related to the school's psychological factors (e.g., high levels of school burnout and stressful environment) and structural characteristics (e.g., early school entrance time) affect youth sleep over time (i.e., decreasing sleep quality and quantity). These main findings provided novel insights into the bidirectional relationship between school experience and sleep health, highlighting the importance of more longitudinal research investigating all aspects of healthy sleep, including the size and direction of the association.

The course of sleep habits in newly diagnosed epilepsy in children: A prospective study

BACKGROUND

Epilepsy and sleep have a close, complex, and reciprocal relationship. Sleep may also be adversely affected by epilepsy and anti-seizure medication (ASM). This study sought to determine sleep-related problems before and after six months of treatment with ASMs follow-up in children with epilepsy, to reveal changes in sleep habits, and to determine the effect of ASMs on sleep in different types of epilepsy.

METHODS

This is a prospective study that included 61 children, aged 4-18 years with newly diagnosed epilepsy, who regularly had follow-up checks and used ASM for six months, and completed the Children's Sleep Habits Questionnaire (CSHQ). Children's Sleep Habits Questionnaire was completed before and after six months of ASM, allowing for assessments based on treatment group and type of epilepsy.

RESULTS

The mean ages of 61 children were 10.6 ± 3.9 years. The participants' post-treatment total scores on the CSHQ decreased by 2.9 ± 7.8 units on average compared to their pretreatment scores (p = 0.008; p < 0.01). In the levetiracetam group, post-treatment CSHQ subscale scores showed a mean decrease for bedtime resistance (p = 0.001), sleep duration (p = 0.005), sleep anxiety (p = 0.030), and total scores (p = 0.012) (p < 0.05). In the valproic acid group, post-treatment CSHQ subscale scores showed a mean decrease in sleep duration (p = 0.007) and a mean increase in daytime sleepiness (p = 0.03) (p < 0.05).

CONCLUSION

Our study found that children diagnosed with epilepsy had significantly higher rates of pretreatment sleep problems, which significantly decreased in patients who regularly attended follow-up examinations and received treatment. Except for the daytime sleepiness factor, our study found that sleep-related problems improved with treatment. It was observed that the initiation of epilepsy treatment had a positive effect on the patient's sleep, regardless of the type of treatment or epilepsy.

Sleep variability and regularity as contributors to obesity and cardiometabolic health in adolescence

OBJECTIVE

Adolescence is a developmental stage of critical changes in sleep and its circadian timing when the contribution of abnormal sleep variability (amount) and sleep regularity (timing) to obesity and its associated adverse cardiometabolic health outcomes appears to increase. The aim of this study was to summarize findings from studies conducted in adolescents examining both sleep variability and regularity in relation to obesity and cardiometabolic health. Gaps in research and potential causal pathways that future studies should examine are highlighted.

RESULTS

Nightly deviations in sleep duration and sleep midpoint appear to contribute to the development of obesity and associated adverse cardiometabolic outcomes in youth. Studies show that increased sleep variability and irregularity are associated with obesity, decreased physical activity, dysregulated eating and inadequate diet, metabolic dysfunction, impaired cardiac autonomic balance, and elevated blood pressure in adolescents.

CONCLUSIONS

A stable circadian timing of sleep is essential to the overall physical well-being of youth. Emerging evidence supports that sleep variability and circadian misalignment, including sleep irregularity, contribute to adverse obesity-related health outcomes early on in adolescence. Future studies should focus on the underlying behavioral and biological mechanisms in the causal pathway between day-to-day deviations in the amount and timing of sleep and obesity.

Health disparities in pediatric sleep-disordered breathing

Sleep-disordered breathing reflects a continuum of overnight breathing difficulties, ranging from mild snoring to obstructive sleep apnea syndrome. Sleep-disordered breathing in childhood is associated with significant adverse outcomes in multiple domains of functioning. This review summarizes the evidence of well-described ethnic, racial, and socioeconomic disparities in pediatric sleep-disordered breathing, from its prevalence to its treatment-related outcomes. Research on potential socio-ecological contributors to these disparities is also reviewed. Critical future research directions include the development of interventions that address the modifiable social and environmental determinants of these health disparities.

Sleep from Infancy Through Adolescence

This article describes the changes in normal sleep regulation, structure, and organization and sleep-related changes in respiration from infancy to adolescence. The first 2 years of age are striking, with more time asleep than awake. With development, the electroencephalogram architecture has a marked reduction in rapid eye movement sleep and the acquisition of K-complexes, sleep spindles, and slow-wave sleep. During adolescence there is a reduction in slow-wave sleep and a delay in the circadian phase. Infants have a more collapsible upper airway and lower lung volumes than older children, which predisposes them to obstructive sleep apnea and sleep-related hypoxemia.

Functional Outcomes, Injury Variables, and Athlete Characteristics Associated with Post-Concussion Sleep Disturbance

OBJECTIVE

To examine the relationship between sleep disturbance and functional outcomes following a concussion. Also, to explore athlete and injury-related variables that may be related to risk factors for poor sleep following concussion.

METHOD

124 collegiate athletes completed a neuropsychological evaluation within 14 days of sustaining a sport-related concussion (SRC). Athletes were categorized as sleep disturbed (n = 52) or not sleep disturbed (n = 72). Outcome variables included symptom reports, cognitive performance (mean performance and variability), and mood (depression). Injury characteristics and athlete characteristics explored were loss of consciousness (LOC) associated with the injury, whether the athlete was immediately removed from play, and history of prior concussions.

RESULTS

Sleep disturbed athletes reported more symptoms, F(4, 119) = 7.82, p < 0.001, ƞ2 = 0.21, were more likely to be symptomatic at the time of testing, χ2(1, N = 124) = 19.79, p < 0.001, φ = 0.40, and were marginally more likely to experience clinically significant depression, χ2(1, N = 120) = 3.03, p = 0.08, φ = 0.16, than not sleep disturbed athletes. There were no cognitive differences between the groups, p > 0.05. A greater proportion of sleep disturbed athletes experienced LOC (30%) compared to not sleep disturbed athletes (13%), χ2(1, N = 118) = 4.99, p = 0.03, φ = -0.21.

CONCLUSION

Sleep disturbances following SRC are associated with a broad range of self-reported symptoms. LOC may be associated with an increased risk of developing sleep disturbances; alternatively, sleep disturbances may increase the risk of LOC following concussion.

Possible sleep bruxism and biological rhythm in school children

OBJECTIVE

To verify whether children with possible sleep bruxism (PSB) had alterations in biological rhythm and to explore the possible factors involved, such as sleep characteristics, screen time, breathing, sugary food consumption, and clenching teeth during wakefulness reported by parents/guardians.

METHODOLOGY

Data were collected through online interviews with 178 parents/guardians of students aged 6 to14 years from Piracicaba, SP, BR, when the BRIAN-K scale was answered, which is composed of four domains (1) sleep; (2) daily routine activities; (3) social behavior; (4) eating; questions about predominant rhythms (willingness, concentration, and change day to night). Three groups were formed: (1) without PSB (WPSB), (2) with PSB sometimes (PSBS), and (3) with PSB frequently (PSBF).

RESULTS

Sociodemographic variables were similar between groups (P > 0.05); the total value of the BRIAN-K was significantly higher for the PSBF group (P < 0.05); the first domain (sleep) presented significantly higher values for the PSB groups (P < 0.05); no significant difference for other domains and predominant rhythms occurred (P > 0.05). The involved factor that differed between groups was clenching teeth, as the number of children with PSBS was significantly higher (χ2, P = 0.005). The first domain of the BRIAN-K (P = 0.003; OR = 1.20), and clenching teeth (P = 0.048; OR = 2.04) were positively associated with PSB.

CONCLUSION

Difficulties in maintaining sleep rhythm and clenching teeth during wakefulness reported by parents/guardians may determine a greater chance to increase the frequency of PSB.

CLINICAL RELEVANCE

Good sleep seems to be important to maintain a regular biological rhythm and may reduce the frequency of PSB in the 6-14 age group.

The effect of modest changes in sleep on dietary intake and eating behavior in children: secondary outcomes of a randomized crossover trial

BACKGROUND

Insufficient sleep duration increases obesity risk in children, but the mechanisms remain unclear.

OBJECTIVES

This study seeks to determine how changes in sleep influence energy intake and eating behavior.

METHODS

Sleep was experimentally manipulated in a randomized, crossover study in 105 children (8-12 y) who met current sleep guidelines (8-11 h/night). Participants went to bed 1 h earlier (sleep extension condition) and 1 h later (sleep restriction condition) than their usual bedtime for 7 consecutive nights, separated by a 1-wk washout. Sleep was measured via waist-worn actigraphy. Dietary intake (2 24-h recalls/wk), eating behaviors (Child Eating Behavior Questionnaire), and the desire to eat different foods (questionnaire) were measured during or at the end of both sleep conditions. The type of food was classified by the level of processing (NOVA) and as core or noncore (typically energy-dense foods) foods. Data were analyzed according to 'intention to treat' and 'per protocol,' an a priori difference in sleep duration between intervention conditions of ≥30 min.

RESULTS

The intention to treat analysis (n = 100) showed a mean difference (95% CI) in daily energy intake of 233 kJ (-42, 509), with significantly more energy from noncore foods (416 kJ; 6.5, 826) during sleep restriction. Differences were magnified in the per-protocol analysis, with differences in daily energy of 361 kJ (20, 702), noncore foods of 504 kJ (25, 984), and ultraprocessed foods of 523 kJ (93, 952). Differences in eating behaviors were also observed, with greater emotional overeating (0.12; 0.01, 0.24) and undereating (0.15; 0.03, 0.27), but not satiety responsiveness (-0.06; -0.17, 0.04) with sleep restriction.

CONCLUSIONS

Mild sleep deprivation may play a role in pediatric obesity by increasing caloric intake, particularly from noncore and ultraprocessed foods. Eating in response to emotions rather than perceived hunger may partly explain why children engage in unhealthy dietary behaviors when tired. This trial was registered at Australian New Zealand Clinical Trials Registry; ANZCTR as CTRN12618001671257.

A developmental perspective on sleep consistency: Preschool age through emerging adulthood

OBJECTIVE/BACKGROUND

Beyond sleep duration, the regularity of sleep patterns (e.g., sleep consistency), including variability in sleep timing (e.g., bedtime, wake time) and duration, is a critical marker of sleep health. Sleep consistency is captured using a variety of methods within the literature (e.g., sleep intraindividual variability, social jetlag), but most of the research focuses on adolescents.

METHODS

Drawing on a developmental perspective, this narrative review highlights how normative changes at the individual (e.g., biological, cognitive, and social) and contextual (e.g., home, school, sociocultural) levels may contribute to inconsistent sleep patterns across development.

RESULTS AND CONCLUSIONS

This review emphasizes how inconsistent sleep may increase across pivotal transitions throughout development (e.g., elimination of naps, puberty, summertime, entering college). Finally, recommendations for measuring sleep consistency and areas to address in future research are discussed.

Extending sleep to improve glycemia: The Family Routines Enhancing Adolescent Diabetes by Optimizing Management (FREADOM) randomized clinical trial protocol

Sleep deficiencies amongst individuals with type 1 diabetes mellitus (T1DM) have been linked with dysregulated glycemic control and greater morbidities. Sleep extension (EXT) has been identified as a viable intervention target to improve adolescent outcomes. The intervention aims to emphasize collaborative work with families to engage in behaviors that increase the likelihood of the youth increasing their sleep duration consistently. This study will randomize up to 175 youth with T1DM and at least one caregiver to either an EXT intervention or a family routines support (FRS) consultation. It is hypothesized that the EXT condition will lead to improvements in sleep, which in turn, will contribute to improved glycemic control. The primary endpoint is improved glycemic control assessed via a continuous glucose monitor (CGM) to ascertain average glucose levels across a week, glycemic variability, and percent time in the target range at one month and HbA1c at three months. Analyses will control for co-morbid conditions, including sleep-disordered breathing and obesity. This study will provide the needed data to support addressing sleep as part of the standards of care in youth with T1DM.

Sleep patterns in childhood: a longitudinal assessment from the Generation XXI birth cohort

OBJECTIVE

To describe sleep-wake patterns in young children, based on sleep characteristics in early infancy and preschool ages, identifying their main sociodemographic characteristics, and to assess the association between different sleep characteristics at both ages.

METHOD

We included 1092 children from the Generation XXI birth cohort, evaluated at six months and four years of age, by face-to-face interviews. Sleep patterns were constructed through latent class analysis and structured equation modeling, including data on wake-up time and bedtime, afternoon naps, locale of nighttime sleep and night awakenings. To estimate the association between sociodemographic characteristics and sleep patterns, odds ratios and 95% confidence intervals were computed using logistic regression.

RESULTS

Two sleep patterns were identified through latent class analysis: pattern 1 was characterized by earlier bedtime and wake-up times, while pattern 2 was defined by later times. When compared with pattern 1, pattern 2 was more frequent among children whose mothers had changed from partnered to not partnered until preschool age and those who did not stay at the kindergarten, and was less common among those with siblings. Through structured equation modeling, an aggregating factor was identified at preschool age, which was mainly correlated with bedtime and wake-up time. A positive association between sleep characteristics evaluated in early infancy and in preschool ages was observed.

CONCLUSIONS

Sleep patterns and circadian sleep preferences seem to be developed early in life, which highlight the importance of promoting an adequate sleep hygiene from infancy, assuming its impact on sleep quality during the life course.

Social-ecological considerations informing a universal screening strategy for sleep health in the community

"Poor sleep health" (PSH), defined as reduced amount of sleep and non-restorative sleep, affects cognitive, social and emotional development. Evidence suggests an association of sleep deprivation and mental health problems; however, there are no universal concepts allowing a first-tier screening of PSH at a community level. The focus of this narrative review is to highlight the cultural context of the current medicalized approach to PSH and to suggest social ecological strategies informing new and holistic community-based screening concepts. We present two conceptual screening frameworks; a "medical" and a merged "social emotional wellbeing framework" and combine them utilizing the concept of "ecologies." The first framework proposes the incorporation of "sleep" in the interpretation of "vigilance" and "inappropriate" labeled behaviors. In the first framework, we provide a logic model for screening the myriad of presentations and possible root causes of sleep disturbances as a tool to assess daytime behaviors in context with PSH. In the second framework, we provide evidence that informs screening for "social emotional wellbeing" in the context of predictive factors, perpetuating factors and predispositions through different cultural perspectives. The distinct goals of both frameworks are to overcome training-biased unidirectional thinking and a priori medicalization of challenging, disruptive and/or disobedient behaviors. The latter has been explicitly informed by the critical discourse on colonization and its consequences, spearheaded by First Nations. Our "transcultural, transdisciplinary and transdiagnostic screening framework" may serve as a starting point from which adaptations of medical models could be developed to suit the purposes of holistic screening, diagnosis, and treatment of complex childhood presentations in different cultural contexts.

A hidden Markov modeling approach combining objective measure of activity and subjective measure of self-reported sleep to estimate the sleep-wake cycle

Characterizing the sleep-wake cycle in adolescents is an important prerequisite to better understand the association of abnormal sleep patterns with subsequent clinical and behavioral outcomes. The aim of this research was to develop hidden Markov models (HMM) that incorporate both objective (actigraphy) and subjective (sleep log) measures to estimate the sleep-wake cycle using data from the NEXT longitudinal study, a large population-based cohort study. The model was estimated with a negative binomial distribution for the activity counts (1-minute epochs) to account for overdispersion relative to a Poisson process. Furthermore, self-reported measures were dichotomized (for each one-minute interval) and subject to misclassification. We assumed that the unobserved sleep-wake cycle follows a two-state Markov chain with transitional probabilities varying according to a circadian rhythm. Maximum-likelihood estimation using a backward-forward algorithm was applied to fit the longitudinal data on a subject by subject basis. The algorithm was used to reconstruct the sleep-wake cycle from sequences of self-reported sleep and activity data. Furthermore, we conduct simulations to examine the properties of this approach under different observational patterns including both complete and partially observed measurements on each individual.

Household food insufficiency and flourishing in a nationally representative sample of young children in the U.S

PURPOSE

This study examined the association between household food insufficiency and flourishing among young children (6 months-5 years) in the U.S. and assessed whether sleep adequacy modifies this association.

METHODS

We used data from the 2018-2020 National Surveys of Children's Health. Adjusted prevalence differences and 95% confidence intervals (CI) for the association between household food insufficiency and flourishing were modeled using average marginal predictions from logistic regression models. Sleep adequacy was assessed as an effect measure modifier on the additive scale.

RESULTS

Evidence supports additive scale effect measure modification of the food insufficiency-flourishing association by sleep adequacy (Likelihood Ratio Test statistic = 12.4, degrees of freedom = 2, P < .05). Adjusted for potential confounders, the prevalence of flourishing was 13.2 percentage points lower (95% CI: -22.6, -3.7) for children in households with insufficient food and inadequate sleep compared to those with sufficient food and adequate sleep.

CONCLUSIONS

Our findings suggest that having enough food and enough sleep are associated with greater wellbeing. These modifiable factors should be targeted by public health interventions to facilitate flourishing among young children in the U.S.

Association between sleep habits and behavioral problems in early adolescence: a descriptive study

Background

Sleep habits are related to children's behavior, emotions, and cognitive functioning. A strong relationship exists between sleep habits and behavioral problems. However, precisely which sleep habits are associated with behavioral problems remains unclear. Therefore, the purpose of this study is to clarify the relationship between sleep habits and behavioral problems in early adolescence.

Methods

This study used data from a larger longitudinal research, specifically, data from the year 2021. First-year junior high school students (12–14 years) in Japan were surveyed; their parents (N = 1288) completed a parent-report questionnaire. The main survey items were subject attributes, the Pittsburgh Sleep Quality Index (PSQI), and the Strength and Difficulties Questionnaire (SDQ).

Results

Of the 652 valid responses received, 604 individuals who met the eligibility criteria (no developmental disability in the child and completion of all survey items) were included in the analysis. To examine the relationship between sleep habits and behavioral problems, logistic regression analysis using the inverse weighted method with propensity score was conducted with sleep habits (sleep quality, time to fall asleep, sleep duration, sleep efficiency, sleep difficulty, use of sleeping pills, difficulty waking during the day, and sleep disturbances) as explanatory variables and behavioral problems (overall difficulty in SDQ) as objective variables. The propensity score was calculated by employing the logistic regression using the inverse weighted method based on propensity scores. Propensity scores were calculated based on gender, family structure, household income, and parental educational background. The results showed that behavioral problems tended to be significantly higher in the group at risk for sleep quality, sleep difficulties, daytime arousal difficulties, and sleep disturbances than in the group with no risk.

Conclusion

The results suggest that deterioration in sleep quality, sleep difficulties, daytime arousal difficulties, and sleep disturbances may increase the risk of behavioral problems in adolescents.

Associations between sociodemographic and behavioural parameters and child development depending on age and sex: a cross-sectional analysis

OBJECTIVES

To explore environmental and individual factors that are associated with child development and to investigate whether the strength of these associations differs according to the age of the children.

DESIGN

Cross-sectional study.

SETTING

This study was part of the LIFE Child study, a large cohort study conducted in Leipzig, Germany.

PARTICIPANTS

778 children aged between 0.5 and 6 years (48.6% girls, mean age=2.67 years).

OUTCOME MEASURES

The outcomes were cognitive development, language development, body and hand motor skills, social-emotional development, and tracing skills, measured with a standardised development test. We analysed the associations between development and gestational age, socioeconomic status (SES), sex, behavioural difficulties, siblings, sleep duration, breastfeeding duration and overweight/obesity. We also tested for interactions between these variables and child age or sex.

RESULTS

Higher gestational age (b ranging between 0.12 and 0.26) and higher SES (b ranging between 0.08 and 0.21) were associated with better outcomes in almost all developmental domains (all p<0.019). Children with older siblings had improved body and hand motor skills compared with children without older siblings (both b=0.55, all p<0.029). Boys had poorer scores than girls in body and hand motor skills and tracing (b=-0.45, -0.68 and -1.5, all p<0.019). Children with behavioural difficulties had significantly poorer outcomes in most developmental domains. Some of the associations with SES and sex were stronger in older than in younger children. Associations between gestational age and motor development were weaker in older children. We did not find significant associations between child development and sleep duration, breastfeeding duration or overweight/obesity.

CONCLUSION

Some factors had a protective, others an adverse effect on development of children under 6 years of age. The effect of SES and sex increased, while the effect of gestational age decreased with age.

TRIAL REGISTRATION NUMBER

NCT02550236.

Insufficient Sleep Syndrome: A Blind Spot in Our Vision of Healthy Sleep

Chronic sleep deficiency (CSD) poses a threat to physical health, mental well-being, and social functioning. The concept of behaviorally induced CSD has not changed much since it was first introduced four decades ago. Behaviorally induced CSD is currently referred to as insufficient sleep syndrome (ISS). In the latest edition of the International Classification of Sleep Disorders (ICSD-3, 2014), ISS is considered a disorder of central hypersomnolence with diagnostic codes ICD-9-CM 307.44 and ICD-10-CM F51.12. In this review, we will describe the biological importance of sleep, the ramifications of CSD on the individual and society, the nosological status and diagnostic features of ISS, and the apparent lack of attention to ISS in contemporary medical practice and public health programs. The last three decades have seen a global rise in voluntary sleep curtailment such that ISS may already be the leading cause of CSD, not only in adults but also in school-aged children and adolescents. Acknowledging ISS as a public health priority is a necessary first step in our response to the global threat of CSD and CSD-related health consequences. It is only by confronting ISS directly that we can hope to develop and implement effective educational and advocacy programs, along with more responsible public health policies and regulations.

Melatonin Treatment for Pediatric Patients with Insomnia: Is There a Place for It?

Sleep is a vital physiological function that is impaired in ranges from 10% in the typically developing pediatric population to over 80% in populations of children with neurodevelopmental disorders and/or psychiatric comorbidities. Pediatric insomnia disorder is an increasing public health concern given its negative impact on synaptic plasticity involved in learning and memory consolidation but also on mood regulation, hormonal development and growth, and its significant impact on quality of life of the child, the adolescent and the family. While first-line treatment of pediatric insomnia should include parental education on sleep as well as sleep hygiene measures and behavioural treatment approaches, pharmacological interventions may be necessary if these strategies fail. Melatonin treatment has been increasingly used off-label in pediatric insomnia, given its benign safety profile. This article aims to identify the possible role of melatonin treatment for pediatric insomnia, considering its physiological role in sleep regulation and the differential effects of immediate release (IR) versus prolonged release (PR) melatonin. For the physician dealing with pediatric insomnia, it is particularly important to be able to distinguish treatment rationales implying different dosages and times of treatment intake. Finally, we discuss the benefit-risk ratio for melatonin treatment in different pediatric populations, ranging from the general pediatric population to children with different types of neurodevelopmental disorders, such as autism spectrum disorder or ADHD.

Physical Activity and Executive Functions in Adolescents: The Mediating Role of Sleepiness

(1) Background: Both physical activity and sleepiness were found to influence the development of executive functioning. The present study aimed to address the effects of different levels of physical activity on adolescents' executive performance (i.e., working memory and inhibition), and the role of sleepiness in this relationship. It was hypothesized that a higher level of physical activity would be associated with better executive functioning, while this relationship was mediated (at least partially) by reduced sleepiness at school. (2) Methods: 212 adolescents aged from 10 to 17 were recruited, and they were requested to wear accelerometers for seven consecutive days to measure daily levels of physical activity. The Cleveland Adolescent Sleepiness questionnaire (CASQ) was used to assess sleepiness. The working memory and inhibition control were assessed to indicate executive functioning. (3) Results: It was found that sedentary activity was negatively associated with working memory performance, while light and moderate-to-vigorous physical activities were related to better working memory. The relationship between different levels of physical activity and working memory was mediated by reduced sleepiness at school. (4) Conclusions: Our findings provide nuanced evidence that the benefits of light and moderate-to-vigorous physical activity on cognitive development could be explained by reduced sleepiness at school.

Translation and language validation of the Epworth sleepiness scale for children and adolescents (ESS-CHAD) into Brazilian Portuguese

OBJECTIVE

This study aimed to translate the Epworth sleepiness scale for children and adolescents (ESS-CHAD) into Brazilian Portuguese.

MATERIAL AND METHODS

The translation and language validation processes were carried out through translation, back translation, technical review, assessment of verbal comprehension/clarity of the scale by experts (four pediatric neurologists). After they have reached a final version of the ESS-HAD a sample of asymptomatic children and adolescents that were participants in another sleep project were invited to read and complete the questionnaire to evaluate comprehension by the aimed population.

RESULTS

Two independent researchers made the forward translation and it has around 90% of concordance. Minor disagreements were related to the position of adjectives in the sentence. No major difficulties were reported by the 3rd researcher that performed the back translation. After a consensus meeting with the four participants, we have reached a final version of the questionnaire. In the cognitive interviews, the scale was reportedly easy to understand to the 23 respondents. One adolescent suggested clarifying whether question 2 (likelihood of falling asleep watching TV or a video), referred to daytime or nighttime. The total ESS-CHAD score in this asymptomatic sample varied from 0-17, a mean score of 7.08±5.65.

DISCUSSION

The final version of the ESS-CHAD in Brazilian Portuguese was approved by the copyright owners and was well understandable by caregivers and adolescents. More studies are now necessary to use this questionnaire in a larger target population to verify its validity and internal consistency.

Associations between Sleep Characteristics and Cardiovascular Risk Factors in Adolescents Living with Type 1 Diabetes

Adolescents living with type 1 diabetes (T1D) have an increased risk of developing cardiovascular disease. Sleep patterns have physiological and behavioral impacts on diabetes outcomes. This study aimed to investigate the associations between sleep patterns and CVD risk factors in adolescents living with T1D and their peers living without T1D. This cross-sectional study assessed CVD risk factors and sleep characteristics (and their associations) in adolescents, aged 12–18 years, living with T1D (n = 48) and their peers (n = 19) without T1D. Outcomes included blood pressure, lipid profiles, and sleep characteristics (accelerometry). Statistical differences between groups were determined with chi-square or independent samples t-tests. The associations between sleep characteristics and CVD risk factors were assessed with multivariate linear regression analyses. We found no significant differences between the two groups in terms of sleep duration, efficiency, sleep onset and offset, and frequency of awakenings, and there were associations between sleep efficiency and LDL-C (β = −0.045, p = 0.018, model R² = 0.230) and triglycerides (β = −0.027, p = 0.012, model R² = 0.222) after adjusting confounders (diabetes status, sex, age, pubertal stage) in all participants. In conclusion, adolescents with T1D and without T1D sleep less than the recommended eight hours per night. The associations between sleep efficiency and LDL-C and triglycerides are independent of sleep duration, regardless of sex, age, and pubertal stage.

Cognitive Behavioral Therapy for Insomnia in School-Aged Children and Adolescents

One of the most prevalent sleep disorders in children and adolescents is "insomnia," which can be briefly described as problems with initiating and/or maintaining sleep with associated daytime consequences. These are typical insomnia symptoms, and when experienced for long enough and when they interfere with an important area of the young person's life (eg, schooling), then a diagnosis of an insomnia disorder may be warranted. The authors strongly urge the scientific community to conduct further controlled trials, including dismantling trials that evaluate the relative effectiveness of individual cognitive behavioral therapy for insomnia components.