Psychometric properties of an omnibus sleep problems questionnaire for school-aged children

Sleep spindles are reduced in children with Down syndrome and sleep-disordered breathing

BACKGROUND

Children with Down syndrome (DS) are at increased risk of sleep-disordered breathing (SDB). We investigated sleep spindle activity, as a marker of sleep quality, and its relationship with daytime functioning in children with DS compared to typically developing (TD) children.

METHODS

Children with DS and SDB (n = 44) and TD children matched for age, sex and SDB severity underwent overnight polysomnography. Fast or Slow sleep spindles were identified manually during N2/N3 sleep. Spindle activity was characterized as spindle number, density (number of spindles/h) and intensity (density × average duration) on central (C) and frontal (F) electrodes. Parents completed the Child Behavior Check List and OSA-18 questionnaires.

RESULTS

In children with DS, spindle activity was lower compared to TD children for F Slow and F Slow&Fast spindles combined (p < 0.001 for all). Furthermore, there were no correlations between spindle activity and CBCL subscales; however, spindle activity for C Fast and C Slow&Fast was negatively correlated with OSA-18 emotional symptoms and caregiver concerns and C Fast activity was also negatively correlated with daytime function and total problems.

CONCLUSIONS

Reduced spindle activity in children with DS may underpin the increased sleep disruption and negative effects of SDB on quality of life and behavior.

IMPACT

Children with Down syndrome (DS) are at increased risk of sleep-disordered breathing (SDB), which is associated with sleep disruption affecting daytime functioning. Sleep spindles are a sensitive marker of sleep quality. We identified for the first time that children with DS had reduced sleep spindle activity compared to typically developing children matched for SDB severity. The reduced spindle activity likely underpins the more disrupted sleep and may be associated with reduced daytime functioning and quality of life and may also be an early biomarker for an increased risk of developing dementia later in life in children with DS.

Effect of sleep disordered breathing severity in children with Down syndrome on parental wellbeing and social support

INTRODUCTION

Sleep disorders, particularly sleep disordered breathing (SDB), are common in children with Down syndrome (DS). We investigated the relationship between SDB severity and parental psychological wellbeing and their perception of social support.

METHODS

44 children with DS (3-19 years) underwent overnight polysomnography and were categorised into three groups: primary snoring, Mild and Moderate/Severe obstructive sleep apnoea (OSA). Parents completed questionnaires about their child's behaviour (Child Behavior Checklist), sleep symptoms (Pediatric Sleep Survey Instrument) and SDB-related quality of life (OSA-18), together with the DUKE-UNC Functional Social Support (DUKE) and Psychological General Well-Being Index (PGWBI) questionnaires for themselves. 34 children completed a follow-up study after 2 years.

RESULTS

There were no significant differences between SDB severity groups for parental perceived social support or psychological wellbeing. Total scores on the DUKE were below average and PGWBI scores were indicative of moderate psychological distress in all three groups. Reduced perceived levels of social support were significantly correlated with externalising child behaviour and sleep disturbance. Diminished parental psychological wellbeing was also significantly correlated with increased sleep disturbances and reduced quality of life in children. At follow-up there were no significant changes in any questionnaire outcome, however parents of children with improved SDB severity had improved PGWBI vitality scores.

CONCLUSION

The degree of parent-reported sleep disturbance in children with DS was linked to suboptimal perceived parental social support and poor psychological wellbeing. Our results emphasise the need for enhanced awareness of the detrimental effects of sleep problems in children with DS on parental wellbeing.

Follow-up of children with Down syndrome and sleep disordered breathing and the effects of treatment on actigraphically recorded sleep, quality of life, behaviour, and daytime functioning

Children with Down syndrome are at increased risk of obstructive sleep disordered breathing, which has deleterious effects on daytime functioning. We aimed to examine the effects of treatment of sleep disordered breathing on sleep quality and daytime functioning in children with Down syndrome, and hypothesised that these would be improved. Thirty-four children completed a baseline study and a follow-up 2 years later. Measures at both time points included 7 days of actigraphy and parents completed a number of questionnaires assessing sleep, behaviour, daytime functioning, and quality of life. All children had overnight polysomnography at baseline; 15 children (44%) were treated. At baseline the treated group had more severe sleep disordered breathing compared with the untreated group: obstructive apneoa-hypopnoea index 29.3 ± 38.2 events/h versus 3.3 ± 5.2 events/h (p < 0.01). Actigraphy showed no significant differences in total sleep time, sleep efficiency, sleep schedules from baseline to follow up in either group. The sleep disturbance (p < 0.01) and total problems (p < 0.05) scales on the OSA-18 and the sleep disordered breathing subscale on the Paediatric Sleep Problem Survey Instrument (p < 0.01) improved in the treated children. There were no changes in any measure in the untreated children. Treatment of sleep disordered breathing improves symptoms, sleep disturbance and quality of life in children with Down syndrome, but has no demonstrable impact on actigraphic sleep measures or daytime behaviour or function. In contrast, children who were not treated, despite having less severe disease at baseline, had increased sleep disruption and no change in quality of life.

Prediction of obstructive sleep apnoea in children and adolescents with Down syndrome

BACKGROUND

Obstructive sleep apnoea (OSA) is common in children and adolescents with Down syndrome (DS). Clinical guidelines recommend that all children with DS have polysomnography (PSG) for assessment of OSA by the age of 4 years, but access is limited and testing may be burdensome for children and families.

METHODS

The purpose of this prospective cross-sectional cohort study was to identify a model to predict OSA in this group that could be tested in an external population to triage children and adolescents with DS for PSG. These models were based on a comprehensive set of potential predictive demographic, anthropometric, quality of life and sleep-related variables.

RESULTS

The results of this study show the predictive power of a model based on the sleep disordered breathing subscale of the Pediatric Sleep Survey Instrument and sleep fragmentation quantified using actigraphy in determining moderate-severe OSA in children and adolescents with DS. This model exhibits high sensitivity (82%), specificity (80%), positive predictive value (75%) and negative predictive value (86%).

CONCLUSIONS

We demonstrate the utility of a tool containing the sleep disordered breathing subscale of the Pediatric Sleep Survey Instrument and sleep fragmentation quantified using actigraphy in identifying children and adolescents with DS who have moderate/severe OSA.

Effects of Treatment of Sleep Disordered Breathing on Sleep Macro- and Micro-Architecture in Children with Down Syndrome

Background: Children with Down syndrome (DS) are at increased risk of obstructive sleep disordered breathing (SDB), which is associated with intermittent hypoxia and sleep disruption affecting daytime functioning. We aimed to examine the effects of treatment of SDB on sleep quality and daytime functioning in children with DS. Methods: Children with DS and SDB (n = 24) completed a baseline and follow-up overnight polysomnographic (PSG) study 22 ± 7 months (mean ± SD) later. Sleep micro-architecture was assessed using EEG spectral analysis, and parents completed a number of questionnaires assessing sleep, behavior, daytime functioning, and quality of life (QOL). Results: A total of nine children (38%) were treated. At baseline, the treated group had more severe SDB compared to the untreated group. SDB severity was significantly improved from 40.3 ± 46.9 events/h to 17.9 ± 26.9 events/h (p < 0.01) at follow up in children who were treated. There were no significant differences in sleep macro-architecture parameters from baseline to follow up in either the treated or untreated group. Sleep micro-architecture was not different between studies in the treated group, however this tended to improve in the untreated group, particularly in REM sleep. Daytime functioning and behavior were not different between the studies in either group, however, QOL improved after treatment. Conclusions: Our study identified that treatment of SDB improves severity of the disease as defined by PSG, and this was associated with parental reports of improved QOL, despite treatment having no demonstrable impacts on sleep quality, behavior, or daytime functioning.

Allergic disease, sleep problems and psychological distress in children recruited from the general community

BACKGROUND

It is unclear which allergic disease is most strongly related to which sleep problem and whether sleep problems may mediate the association between allergic disease and psychological distress. There is also a need for more community-based studies using non-referred samples.

OBJECTIVE

To examine the association between individual allergic diseases and sleep problems and test whether the association between allergic disease and psychological distress is mediated through sleep problems.

METHODS

Parents of 1449 Australian children aged 6-10y recruited from the general community completed measures of sleep problems (Pediatric Sleep Survey Instrument), psychological distress (Strengths and Difficulties Questionnaire), and frequency of allergic disease.

RESULTS

Sleep and psychological distress scores were in the normal range. After controlling for co-existing allergic diseases: allergic rhinitis was associated with sleep routine problems, morning tiredness, night arousals, sleep disordered breathing and restless sleep; asthma with sleep routine problems, sleep disordered breathing and restless sleep; and eczema with restless sleep. Path analyses revealed that sleep problems mediated the association between asthma and allergic rhinitis but not eczema with psychological distress.

CONCLUSION

In this non-referred community sample, the frequency of sleep problems and psychological distress was lower than that typically reported in children referred to specialized centres. However, allergic rhinitis was associated with a broad range of sleep problems and to a lesser extent in children with asthma and least in children with eczema. Path analysis revealed that the association between allergic disease and psychological distress was mediated through sleep problems highlighting the importance of assessing sleep health in children with allergic disease.

Short report: Sleep talking and mental health in children with developmental problems and typically developing children

BACKGROUND

Sleep talking although often considered benign is associated with poor mental health. However, it remains to be tested whether this association may be better explained by the presence of co-morbid sleep problems and the presence in survey samples of children with development disorders who tend to report a higher frequency of both sleep problems and poor mental health.

AIM

The aim of the present study was to examine the association between sleep talking and mental health after controlling for comorbid sleep problems in typically developing children and children with developmental problems.

METHODS

Parents of typically developing children (n = 1609) and children with either intellectual or developmental delay (n = 128) aged 5-10 years completed an omnibus survey which was administered through participating South Australian primary schools assessing mental health (Strengths and Difficulties Questionnaire) and sleep problems (Paediatric Sleep Survey Instrument).

RESULTS

After controlling for co-morbid sleep problems, regression analyses revealed that sleep talking in typically developing children was an independent but weak predictor of worse emotional symptoms, conduct problems and peer relationship problems. By contrast, only a single significant association was observed in children with developmental problems. Paradoxically, sleep talking was associated with better prosocial behaviour.

CONCLUSION

It is suggested that in typically developing children with a history of sleep talking, mental health merits evaluation at clinical interview while in both typically developing children and children with developmental problems, co-morbid sleep problems merit evaluation.

The Impact of Preterm Birth on Sleep through Infancy, Childhood and Adolescence and Its Implications

There is emergent literature on the relationship between the development of sleep-wake cycles, sleep architecture, and sleep duration during the neonatal period on neurodevelopmental outcomes among children born preterm. There is also a growing literature on techniques to assess sleep staging in preterm neonates using either EEG methods or heart and respiration rate. Upon discharge from hospital, sleep in children born preterm has been assessed using parent report, actigraphy, and polysomnography. This review describes the ontogeny and measurement of sleep in the neonatal period, the current evidence on the impact of preterm birth on sleep both in the NICU and in childhood and adolescence, and the interaction between sleep, cognition, and social-emotional outcomes in this population.

Effects of Bacopa monnieri (CDRI 08®) in a population of males exhibiting inattention and hyperactivity aged 6 to 14 years: A randomized, double-blind, placebo-controlled trial

The current study investigated the efficacy of extract of Bacopa monnieri (BM; CDRI 08®) in reducing levels of inattention and hyperactivity in young children. BM has demonstrated improvements in cognitive outcomes in adults, yet little research is available on its effects in younger populations. A 14-week randomized, double-blind, placebo-controlled clinical trial, with placebo run-in and run-out phases, investigated the effects of BM on behavioural, cognitive, mood, and sleep effects in male children aged 6 to 14 years against placebo. One-hundred and twelve participants were recruited into the trial, with 93 datasets available for analysis. No significant behavioural differences were noted between treatment groups. Cognitive outcomes indicated decreased error-making in children taking CDRI 08® (p = .04) and increased speed of reaction time in those taking placebo (p = .04) at study end. Improvements in cognitive flexibility (p = .01), executive functioning (p = .04), interpersonal problems (p = .02), and sleep routine (p = .04) were noted in those consuming CDRI 08® over placebo. CDRI 08® did not improve behavioural outcomes, but may have cognitive, mood and sleep benefits in children aged 6 to 14 years. Further study is required to support the findings presented here.

Factors associated with referral for polysomnography in children with Down syndrome

OBJECTIVES

Children with Down syndrome (DS) are recommended to undergo polysomnography (PSG) by the age of four years due to the high prevalence of obstructive sleep apnea (OSA) in this group, but compliance is incomplete. To further understand referral patterns for PSG in this condition, we aimed to compare demographics, PSG results, OSA severity, behavior, daytime functioning and quality of life (QOL) between children with DS referred for sleep testing and those recruited from the community.

STUDY DESIGN

Children 3-19 years with DS was included: 20 referred clinically for assessment of OSA and 24 volunteers from the community. Demographic and anthropometric data, PSG parameters, sleep-related symptoms and QOL, behavior and daytime functioning were compared between groups.

RESULTS

OSA severity did not differ between groups: 50% of the clinical and 42% of the community group had moderate/severe OSA. The clinical group had a higher weight z-score, BMI z-score, waist and hip circumference and neck-to-waist ratio. Questionnaire scores for daytime functioning, behavior and QOL were not different between groups.

CONCLUSIONS

Despite not being referred for clinical sleep assessment, 42% of children with DS recruited from the community had moderate/severe OSA. There was no difference in the QOL, behavior, daytime functioning and sleep symptoms questionnaires although the clinical group had a higher BMI-Z score and overt signs of obesity. These findings underscore the importance of PSG screening of all children with DS.

Restless sleep in children: A systematic review

This systematic review assessed the prevalence of restless sleep in children, documented the association of restless sleep with other conditions, and summarized the existing evidence regarding whether restless sleep should be considered a distinct sleep disorder. A comprehensive search of electronic databases was performed using the broad search term "restless sleep" in all fields. Of the 266 articles retrieved, 107 were retained for inclusion in this review. The majority (n = 93) were observational studies. The studies were grouped under several pathologic/condition categories: sleep-disordered breathing (n = 19); adenotonsillectomy (n = 7); respiratory disorders, otitis media, and smoke exposure (n = 12); sleep-related movement disorders and restless sleep disorder (n = 11); neurologic or psychiatric disorders (n = 7); Down syndrome/other neurodevelopmental disorders (n = 10); sleep-related bruxism and other sleep disorders (n = 7); and restless sleep in the general population/mixed clinical samples (n = 18). A high prevalence of restless sleep was found in children with many of these underlying conditions, likely related to associated inherent sleep disruption and frequent awakenings (e.g., apnea and periodic limb movements), pain, sleep instability, and caregiver perception. The majority of studies identified restless sleep as reported by the caregiver, only 34 studies attempted to define restless sleep further. Four studies provided supportive evidence for designating restless sleep as an independent sleep disorder, restless sleep disorder (RSD). This review highlights the fact that the prevalence, etiology and sequelae (including daytime impairments) of restless sleep in children are important topics deserving of further research and that clinical definitions based on empirical evidence need to be developed. The designation of "primary" versus "secondary" restless sleep may be a useful construct, especially with regard to developing clinical trials and treatment algorithms.

Pediatric Sleep Tools: An Updated Literature Review

Since a thorough review in 2011 by Spruyt, into the integral pitfalls of pediatric questionnaires in sleep, sleep researchers worldwide have further evaluated many existing tools. This systematic review aims to comprehensively evaluate and summarize the tools currently in circulation and provide recommendations for potential evolving avenues of pediatric sleep interest. 144 "tool"-studies (70 tools) have been published aiming at investigating sleep in primarily 6-18 years old per parental report. Although 27 new tools were discovered, most of the studies translated or evaluated the psychometric properties of existing tools. Some form of normative values has been established in 18 studies. More than half of the tools queried general sleep problems. Extra efforts in tool development are still needed for tools that assess children outside the 6-to-12-year-old age range, as well as for tools examining sleep-related aspects beyond sleep problems/disorders. Especially assessing the validity of tools has been pursued vis-à-vis fulfillment of psychometric criteria. While the Spruyt et al. review provided a rigorous step-by-step guide into the development and validation of such tools, a pattern of steps continue to be overlooked. As these instruments are potentially valuable in assisting in the development of a clinical diagnosis into pediatric sleep pathologies, it is required that while they are primary subjective measures, they behave as objective measures. More tools for specific populations (e.g., in terms of ages, developmental disabilities, and sleep pathologies) are still needed.

The OSA-5: Development and validation of a brief questionnaire screening tool for obstructive sleep apnea in children

OBJECTIVE

To develop and test a screening tool based on the OSA-18 questionnaire for triage of referrals for sleep-disordered breathing (SDB) in children.

STUDY DESIGN

Consecutive children aged >2y without major comorbidities referred for polysomnography (PSG) or overnight oximetry for suspected obstructive sleep apnea (OSA) between 11 January and 31 May 2017 were included. OSA was defined by an obstructive apnea/hypopnea index (OAHI) >1event/h on PSG or an abnormal overnight oximetry (McGill Oximetry Score 2-4). An 11-item questionnaire derived from a previous validation study of the OSA-18 underwent exploratory factor analysis (EFA) with varimax rotation. ANOVA identified questions associated with the presence of OSA. This informed a 5-question, 4-category instrument, scored 0-15 (the OSA-5), that was tested prospectively on 112 children having PSG.

RESULTS

420 children (2.0-17.9y, 43% female) met the inclusion criteria, including 366 complete questionnaires. EFA resulted in a 3-factor structure. ANOVA identified 5 questions from one factor that were independently associated with a diagnosis of OSA: snoring, breath holding, choking, mouth breathing and parental concern. Mean OSA-5 scores with and without OSA were 7.7 vs 4.5 (p < 0.001). Thirty-four percent (60/178) had a total score <5/15, with a sensitivity at this threshold for OSA of 82% and negative predictive value (NPV) of 70%. Similar results were obtained when tested prospectively, including a sensitivity of 82% and NPV of 81% for the presence of moderate/severe OSA (OAHI>5/h).

CONCLUSION

The OSA-5 is a simple questionnaire that performs well as a triage screening tool to identify those children at risk of OSA among large numbers of referrals for SDB.

Japanese Sleep Questionnaire for Elementary Schoolers (JSQ-ES): validation and population-based score distribution

OBJECTIVE

The Japanese Sleep Questionnaire for Elementary Schoolers (JSQ-ES) was developed to measure the sleep habits and disturbances of Japanese children. The current study aimed to present psychometric properties and describe the score distribution of the JSQ-ES. In addition, it examined correlations between the sleep and daytime behavior of school-aged children.

METHOD

Guardians of 4369 elementary school children and 100 children diagnosed with sleep disorders in two clinics completed the JSQ-ES.

RESULTS

Exploratory factor analysis and confirmatory factor analysis suggested a nine-factor structure. The JSQ-ES internal consistency was 0.876 and 0.907 for the community and clinical groups, respectively. Score distribution differences were observed between the two groups. A cut-off point of 80 was identified for the total JSQ-ES score.

CONCLUSIONS

Exploratory factor analysis and confirmatory factor analysis suggested a nine-factor structure: (1) restless legs syndrome; (2) sleep-disordered breathing; (3) morning symptoms; (4) nighttime awakenings; (5) insomnia; (6) excessive daytime sleepiness; (7) daytime behavior; (8) sleep habits; and (9) irregular/delayed sleep phase. The study verified that the JSQ-ES is a valid and reliable instrument with which to evaluate Japanese sleep habits using a large population-based sample. The JSQ-ES may be useful in both clinical and academic settings.

The Relationship Between Caffeine, Sleep, and Behavior in Children

STUDY OBJECTIVES

To examine caffeine consumption from various dietary sources in a cohort of Australian children and the relationship between caffeine consumption, sleep, and daytime behavior.

METHODS

Children aged 8 to 12 years and their parents/guardians completed a battery of questionnaires. Children completed a caffeine questionnaire while parents completed questionnaires regarding demographics, sleep, and behavior.

RESULTS

The final sample consisted of 309 children (mean ± standard deviation [SD] age 10.6 ± 1.3 years, male = 48%) and corresponding parent reports. On average a mean ± SD 10.2 ± 17.4 mg/day of caffeine was consumed with a range of zero to 151 mg/day. Of the children who consumed caffeine (87% of the sample), the largest contributor was coffee and tea; making up 41% of total caffeine intake, and sodas (soft drinks) contributed to 40% of caffeine intake. Total caffeine consumption was significantly associated with sleep routine (r = 0.152); morning tiredness (r = 0.129); restless sleep (r = 0.113); and internalizing behavioral problems (r = 0.128). Using path analysis, caffeine consumption was positively associated with morning tiredness (β = 0.111, P = .050) which was positively associated with internalizing behaviors (β = 0.432, P < .001). The addition of sleep routine and restless sleep to the model led to a complete mediation of caffeine consumption on morning tiredness, as well as a partial mediation of the association between morning tiredness and internal behaviors.

CONCLUSIONS

In 8- to 12-year-olds the primary sources of caffeine are coffee/tea and sodas. Overall mean caffeine consumption is small by adult standards but has an effect on behavior and sleep in children. The effect on behavior is mediated by disrupted sleep, indicating that caffeine is a contributor to sleep problems and related behavior in children.

A Randomized Controlled Trial Investigating the Effects of a Special Extract of Bacopa monnieri (CDRI 08) on Hyperactivity and Inattention in Male Children and Adolescents: BACHI Study Protocol (ANZCTRN12612000827831)

Clinical diagnoses of Attention Deficit Hyperactivity Disorder (ADHD) and the use of prescription medications for its treatment have increased in recent years. Current treatments may involve the administration of amphetamine-type substances, a treatment path many parents are apprehensive to take. Therefore, alternative pharmacological treatments are required. Few nutritional or pharmacological alternatives that reduce ADHD associated symptoms (hyperactivity and inattention) have been subjected to rigorous clinical trials. Bacopa monnieri is a perennial creeping herb. CDRI 08 is a special extract of Bacopa monnieri which has been subjected to hundreds of scientific studies and has been shown in human randomized controlled trials (RCTs) to improve memory, attention, and mood. It is hypothesised that chronic administration of CDRI 08 will improve attention, concentration and behaviour in children with high levels of hyperactivity and/or inattention. This paper reports the protocol for the first 16-week, randomized, placebo-controlled, double-blind, parallel groups trial examining the efficacy and safety of CDRI 08 in male children aged 6–14 years with high levels of inattention and hyperactivity. The primary outcome variable will be the level of hyperactivity and inattention measured by the Conners’ Parent Rating Scale (CPRS). Secondary outcome variables include cognition, mood, sleep, and EEG. Trial registration: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000827831.