Does context matter? A multilevel analysis of neighborhood disadvantage and children's sleep health

Greater Neighborhood Disadvantage Is Associated with Alterations in Fetal Functional Brain Network Structure

OBJECTIVE

To determine the association between neighborhood disadvantage and functional brain development of in utero fetuses.

STUDY DESIGN

We conducted an observational study utilizing Social Vulnerability Index (SVI) scores to assess the impact of neighborhood disadvantage on a prospectively recruited sample of healthy pregnant women from Washington, DC. Utilizing 79 functional MRI scans from 68 healthy pregnancies at a mean gestational age of 33.12 weeks, we characterized overall functional brain network structure using a graph metric approach. We utilized linear mixed effects models to assess the relationship between SVI and gestational age on five graph metrics, adjusting for multiple scans.

RESULTS

Exposure to greater neighborhood disadvantage was associated with less well integrated functional brain networks, as observed by longer characteristic path lengths (L) and diminished global efficiency (GE) as well as diminished small world propensity (SWP). Across gestational ages, however, the association between SVI and network integration diminished to a negligible relationship in the third trimester. Conversely, SWP was significant across pregnancy, but the relationship changed such that there was a negative association with SWP earlier in the second trimester that inverted around the transition to the third trimester to a positive association.

CONCLUSIONS

These data directly connect neighborhood disadvantage and altered functional brain maturation in fetuses. Our results suggest that even prior to birth, proximity to environmental stressors in the wider neighborhood environment are associated with altered brain development.

Socioeconomic factors, sleep timing and duration, and amygdala resting-state functional connectivity in children

Introduction

Reduced sleep health has been consistently linked with increased negative emotion in children. While sleep characteristics have been associated with neural function in adults and adolescents, much less is known about these associations in children while considering socioeconomic context. In this study, we examined the associations among socioeconomic factors, sleep duration and timing, and resting-state functional connectivity (rsFC) of the amygdala in children.

Methods

Participants were typically-developing 5- to 9-year-olds from socioeconomically diverse families (61% female; N = 94). Parents reported on children's weekday and weekend bedtimes and wake-up times, which were used to compute sleep duration and midpoint. Analyses focused on amygdala-anterior cingulate cortex (ACC) connectivity followed by amygdala-whole brain connectivity.

Results

Lower family income-to-needs ratio and parental education were significantly associated with later weekday and weekend sleep timing and shorter weekday sleep duration. Shorter weekday sleep duration was associated with decreased amygdala-ACC and amygdala-insula connectivity. Later weekend sleep midpoint was associated with decreased amygdala-paracingulate cortex and amygdala-postcentral gyrus connectivity. Socioeconomic factors were indirectly associated with connectivity in these circuits via sleep duration and timing.

Discussion

These results suggest that socioeconomic disadvantage may interfere with both sleep duration and timing, in turn possibly altering amygdala connectivity in emotion processing and regulation circuits in children. Effective strategies supporting family economic conditions may have benefits for sleep health and brain development in children.

Substituting Book Reading for Screen Time Benefits Preschoolers' Sleep Health: Results from the Ulm SPATZ Health Study

Purpose

Healthy sleep is essential for the physical, cognitive, and social development of children. Several studies have reported the increase in digital media use in preschool children and its association with impaired sleep. However, there is relatively little evidence on the effects of book reading as a potentially safe alternative. The objective of this study, therefore, was to investigate whether sleep in children could benefit from book reading, and whether the negative effects of media use on sleep can be mitigated by substituting book reading for screen time.

Participants and Methods

We used longitudinal data from three consecutive waves of the SPATZ Health study, including children at the ages of 4 (n=581), 5 (n=508), and 6 (n=426) years. All data were collected by self-administered questionnaires. Parent-reported child sleep was assessed by the Children's Sleep Habits Questionnaire.

Results

Across the three waves, screen-based media use increased and was associated with lower sleep quality. In contrast, the time spent with book reading decreased; however, book reading appeared to be beneficial for children's sleep. Substitution models revealed that the theoretical substitution of an equal amount of book reading for 50% of the time spent with screen-based media benefits several domains of preschoolers' sleep health, including parasomnias, sleep anxiety, daytime sleepiness, and sleep onset delay.

Conclusion

Besides implications for population-wide and individual prevention, book reading may also be incorporated as a useful intervention to improve sleep quality in children who are already affected by sleep problems. Given that book reading is perceived as a safe alternative, the presented evidence may suffice to support recommendations in this direction.

Early emergence of racial and ethnic differences in sleep health among toddlers living in low-income families

OBJECTIVES

Emerging evidence suggests racial and ethnic and socioeconomic differences in children's sleep health, yet few have examined these differences among very young children. The purpose of this study is to identify potential racial, ethnic, and sociodeomographic factors associated with multiple dimensions of sleep health in toddlers living in very low-income families.

PARTICIPANTS

Sample included 110 racially and ethnically diverse dyads with toddlers aged 12-15 months living in low-income families.

METHODS

Actigraph data (9 days and nights), caregiver completed sleep diaries, Brief Infant Sleep Questionnaire-extended, and caregiver-reported socioeconomic characteristics were collected.

RESULTS

Toddlers' average sleep duration (10.25 hours; SD = 0.76) was less than the age-based recommendations. There were significant race and ethnic differences in toddler's actigraph-measured bedtime (p < .001) and variability in bedtimes (p = .004). Non-LatinX White toddlers had earlier bedtimes and less variability than Black and LatinX children. These between-group differences remained statistically significant after controlling for measured socioeconomic variables (p's < 0.001). Within racial and ethnic group differences in bedtime and bedtime variability by education, employment, and marital status were identified with medium to large effect sizes.

CONCLUSIONS

Racial and ethnic between-group differences in sleep occurred as early as 12 months of age and were not explained by sociodemographic variables (eg, income-to-needs, education, housing). Further research is necessary to determine structural and contextual factors that explain the racial and ethnic differences in sleep health in early childhood. Identifying these factors may inform the development of socially and culturally tailored interventions to reduce sleep health disparities.

The development of a scale to assess children's and adolescents' sleep environments

STUDY OBJECTIVES

To develop a measure of children's sleep environments and to assess its initial reliability and validity.

METHODS

This cross-sectional study consisted of an online survey for parents of children ages 5-18 years across the United States. A total of 840 parents/caregivers (Mage = 40.6 years, standard deviation = 8.6; 72.0% female) completed surveys regarding a target child (Mage = 10.4 years, standard deviation = 3.8). The items on the scale that was developed were evaluated with exploratory and confirmatory factor analyses in separate random sample halves of the dataset. Cronbach's alpha coefficients were calculated to assess internal consistency across multiple demographic groups. We explored convergent and discriminant validity by examining associations with measures from the nomological net of constructs surrounding the children's sleep environment. Finally, we examined incremental/unique predictive validity of the full scale and its subscales through regression analyses.

RESULTS

The Children's and Adolescents' Sleep Environment Scale (13 items) produced 3 factors: general environmental hazards (7 items), availability of bedding materials (2 items), and presence of electronics (4 items). The full scale and its subscales showed strong discriminant validity, and analyses suggested that the Children's and Adolescents' Sleep Environment Scale and its subscales were generalizable across diverse demographic groups. Finally, after controlling for children's sleep hygiene, sleep disturbances, behavioral problems, and family functioning, the full-scale Children's and Adolescents' Sleep Environment Scale significantly predicted children's sleepiness, as did the general environmental hazards and presence of electronics subscales in a separate regression analysis.

CONCLUSIONS

The Children's and Adolescents' Sleep Environment Scale shows strong psychometric properties and has emerged as both a reliable and valid indicator of children's and adolescents' sleep environments and their potential impact on children's sleep and sleep-related behavior.

CITATION

Peltz JS, Rogge RD, Elmore-Staton L, Spilsbury J, Buckhalt JA. The development of a scale to assess children's and adolescents' sleep environments. J Clin Sleep Med. 2022;18(10):2353-2365.

Examining the interactive association of family- and neighborhood-level socio-economic characteristics on children's sleep beyond the associations of residency and neighborhood violence

OBJECTIVE

To examine the interactive association of neighborhood and family socio-economic characteristics (SEC) on children's sleep.

DESIGN

Secondary data analyses were completed on the 2014 Ontario Child Health Study, a cross-sectional sample of 10,802 children aged 4-17.

PARTICIPANTS

Children (aged 4-11, 50% male; N = 6264) with available sleep outcome data.

METHODS

Multilevel modeling was used to assess the interactive relationship between family- and neighborhood-level poverty in relation to child sleep outcomes (problems falling asleep, problems staying asleep, weekday and weekend time in bed), above the associations of variables known to be related to sleep at the child (ie, child age, sex, internalizing problems, externalizing problems, chronic illness), family (ie, negative parenting behaviors, family structure, parent mental health, years lived in neighborhood, parent education level), and neighborhood levels (ie, neighborhood size, antisocial behavior).

RESULTS

Neighborhood poverty (p < .01, ß = -0.001, 95% confidence interval [-0.007, -0.002]) was significantly related to shorter weekday time in bed and the interactive association of family and neighborhood poverty was significantly related to weekend time in bed (p < .05, ß = 0.012, 95% confidence interval [0.004, 0.021]). Children living in low poverty neighborhoods with families of higher SEC backgrounds, and children living in high poverty neighborhoods with families of lower SEC backgrounds had the shortest weekend time in bed (9.7 hours).

CONCLUSIONS

There is a compound relationship of family and neighborhood poverty on children's sleep above and beyond family- and child-level risk factors.

Effects of a Sleep Health Education Program for Children and Parents on Child Sleep Duration and Difficulties: A Stepped-Wedge Cluster Randomized Clinical Trial

IMPORTANCE

Preschool-aged children often lack sufficient sleep and experience sleep difficulties. A consistent bedtime routine, falling asleep alone, and other sleep practices reduce difficulties and increase sleep duration.

OBJECTIVE

To evaluate the effects of a preschool-based sleep health literacy program on children's sleep duration and difficulties and on parent sleep knowledge, attitudes, self-efficacy, and beliefs 9 and 12 months after the program.

DESIGN, SETTING, AND PARTICIPANTS

This stepped-wedge cluster randomized clinical trial was implemented across the 2018-2019 school year. Head Start preschool personnel delivered interventions and collected outcomes data at baseline and 4 follow-ups. Seven Head Start agencies across New York State were randomized to implement interventions in either fall 2018 or winter and spring 2019. Outcomes were ascertained at 9- and 12-month follow-up. From March 19 through September 28, 2018, Head Start staff recruited (a) English- or Spanish-speaking parents (b) of children 3 years of age on or about September 2018 (c) who planned to remain at the site through the school year. Altogether, 519 parent-child (aged 3 years) dyads completed baseline and (any) follow-up data.

INTERVENTIONS

A 2-week classroom curriculum for children, a 1-hour parent workshop, and 1-on-1 parent discussions at home or school.

MAIN OUTCOMES AND MEASURES

Outcomes were the pre- vs postintervention differences measured at baseline and 9-month follow-up for parent-reported child school-night sleep duration per sleep logs, mild or moderate sleep difficulties per a validated questionnaire, and the total and domain scores for parent sleep knowledge, attitudes, self-efficacy, and beliefs. A modified intention-to-treat analysis excluding participants with only baseline data was used.

RESULTS

The mean (SD) age at enrollment of 519 children was 2.7 (0.1) years, 264 (50.9%) were girls, 196 (37.8%) lived in Spanish-speaking households, and 5 (0.9%) identified as Alaskan Native or American Indian, 17 (3.2%) as Asian American or Pacific Islander, 57 (10.8%) as Black, 199 (37.8%) as White, and 63 (12.0%) as other. Mean sleep durations increased nonsignificantly from baseline by 5.6 minutes (95% CI, -2.3 to 13.6 minutes; P = .17) at 9-month follow-up and by 6.8 minutes (95% CI, 0.2-13.7 minutes; P = .06) at 12-month follow-up. There was a slight improvement in parental knowledge (1.13 unit increase from baseline; 95% CI, 0.13-2.12 units), but no significant outcomes for parent sleep attitudes (0.16 unit increase from baseline; 95% CI, -0.46 to 0.77 units), self-efficacy (-0.13 unit decrease from baseline; 95% CI, -1.02 to 0.76 units) and beliefs (-0.20 unit decrease from baseline; 95% CI, -0.56 to 0.16 units). Intervention effects for child sleep difficulties were not significant (odds ratio, 1.13; 95% CI, 0.62-2.09). Fewer than 1 in 4 parents accurately perceived their child's sleep difficulty at 12 months.

CONCLUSIONS AND RELEVANCE

The findings of this large pragmatic, stepped-wedge cluster randomized clinical trial, albeit largely negative, may have implications for the sustained impact, focus, and potential population-level effects of sleep education programs. Future research should evaluate the effects of more recurrent programming that emphasizes recognition of sleep problems and whether small increments of sleep across months and years in early childhood have meaningful effects.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03556462.

Correlates of a caregiver-reported child sleep problem and variation by community disadvantage

BACKGROUND

Previous studies of sleep patterns and perceived problems in early childhood indicate variation by family socioeconomic status. The purpose of this study was to examine variation in correlates of a caregiver-perceived child sleep problem across and within levels of community disadvantage in a large US sample.

METHODS

Caregivers of 14,980 young children (ages 0-35.9 months) in the US completed the Brief Infant Sleep Questionnaire-Revised (BISQ-R) on the freely and publicly available Johnson's® Bedtime® Baby Sleep App. Zip code was used to identify a Distressed Communities Index (DCI) score, which represents community disadvantage based on neighborhood indicators.

RESULTS

Across all levels of community disadvantage, caregivers who reported greater impact of child sleep on their own sleep, bedtime difficulty, more frequent and longer night wakings, and increased total nighttime sleep were more likely to endorse a child sleep problem. These associations varied by level of community disadvantage. For caregivers living in more disadvantaged communities, impact of child sleep on their own sleep and night wakings were the strongest correlates of endorsing a child sleep problem, whereas for those in more advantaged communities the impact of child sleep on their own sleep and night wakings as well as additional aspects of sleep health, such as short sleep duration, were associated with endorsement of a child sleep problem.

CONCLUSIONS

Findings suggest that families living in more distressed communities are most likely to identify the impact of child sleep on their own sleep and night wakings in reporting a child sleep problem, whereas those from more prosperous communities consider these factors as well as other sleep parameters, including sleep duration. Clinicians should consider expanding screening questions for child sleep problems to include the perceived impact on caregiver sleep.

Neighborhood environments and sleep among children and adolescents: A systematic review

Understanding salient environmental determinants of pediatric sleep is essential for informing interventions and public health initiatives. Emerging evidence suggests that the neighborhood environment can impact pediatric sleep, but this evidence has not yet been systematically reviewed. We conducted a systematic review of the scientific literature on associations between neighborhood environments and sleep in young children (0-5 y), school-aged children (6-12 y) and adolescents (13-18 y). We reviewed 85 articles published between 2003 and 2020. The most commonly examined neighborhood exposure was low socioeconomic status (40 studies), which was associated with sleep outcomes in 58% of studies (primarily shorter sleep duration, later sleep timing, or obstructive sleep apnea). Evidence was stronger for neighborhood safety/crime/violence (21 studies), with 86% of studies reporting associations with sleep outcomes (primarily self- or caregiver-reported sleep problems). Fewer studies examined associations of neighborhood physical environment exposures, including noise (15 studies), the built environment (seven studies), and air pollution (six studies). Limitations of the current body of evidence include 1) limited examination of neighborhood exposures other than socioeconomic status or safety, 2) use of primarily cross-sectional observational study designs, 3) lack of objective sleep outcome assessment, and 4) limits of current exposure assessment methods.

Socioeconomic disadvantage and sleep in early childhood: Real-world data from a mobile health application

OBJECTIVES

To examine whether increased socioeconomic disadvantage, indexed using a measure of community distress, was associated with variation in caregiver-reported early childhood sleep patterns and problems in a large US sample using a mobile health application (app).

DESIGN

Cross-sectional.

SETTING

Data were collected using the free, publicly available Johnson's Bedtime© baby sleep app.

PARTICIPANTS

A total of 14,980 caregivers (85.1% mothers) of children ages 6-35.9 months (M = 13.88 months; 52.6% boys) participated in this study.

MEASURES

Caregivers reported on child sleep using the Brief Infant Sleep Questionnaire-Revised. Socioeconomic disadvantage was indexed by zip code using the Distressed Communities Index (DCI), which combines seven US census indicators of socioeconomic disadvantage. DCI scores range from prosperous (lowest quintile) to distressed (highest quintile).

RESULTS

Socioeconomic disadvantage was significantly associated with later bedtimes, longer sleep onset latency, and shorter nighttime and 24-hour (total) sleep duration, with children living in distressed communities showing the poorest sleep. However, caregivers living in distressed communities reported a significantly lower prevalence of overall child sleep problems (43% vs 58% in prosperous communities), and more confidence in managing child sleep (42% vs 34% in prosperous communities).

CONCLUSIONS

Children living in the most distressed communities have the poorest reported sleep patterns and bedtime behaviors; however, their caregivers are less likely to report problematic child sleep. These findings highlight the need for community-level sleep health promotion interventions, as well as further investigation of caregiver perceptions about child sleep and sleep health promotion among families living in socioeconomically disadvantaged contexts.

The contributory role of the family context in early childhood sleep health: A systematic review

Sleep-wake regulation is established during early childhood and contributes to life-long health. The family context is critical to the development of child sleep-wake regulation. The primary aim of this systematic review was to elucidate family-level constructs (outside of bedtime parenting) that contribute to early childhood (age 0-5 years) sleep health. We identified empirical research articles that investigate these relationships through systematically searching PubMed, Web of Science, and PsycINFO databases. The transactional model of sleep-wake regulation guided the selection of family-level search terms, including socioeconomic status (SES), family structure, household chaos, marital, co-parenting, and social relationships. Sleep search terms included sleep problems, duration, timing, and variability. We searched sleep and family terms in combination with infant, toddler, or preschool developmental age. Sixteen studies satisfied criteria for inclusion. Results indicated that the presence of household chaos and poor quality marital relationships were directly associated with early childhood sleep problems and variable sleep timing. Higher marital satisfaction and the presence of household routines were positively associated with sleep duration. Several, but not all, studies showed an association between lower SES and poor child sleep health. There were no significant direct associations for family structure and limited findings for the role of perceived social support and co-parenting relationship quality. Overall, operationalization and measurement of family and sleep constructs varied across studies, decreasing our ability to make comparisons and draw robust conclusions. Future research should identify modifiable family-level factors that can be targeted, in addition to bedtime parenting, to improve sleep-wake regulation development.

The Validity, Reliability, and Feasibility of Measurement Tools Used to Assess Sleep of Pre-school Aged Children: A Systematic Rapid Review

Background: Sleep of pre-school aged children is important for their health and development, but there are currently no standards for measuring sleep in this age group. We aimed to examine the validity, reliability and feasibility of tools used to assess sleep of pre-school aged children. Methods: Studies were eligible for inclusion if they examined the validity and/or reliability and/or feasibility of a measurement tool used to examine sleep of pre-school aged children (aged 3-7 years). We systematically searched six electronic databases, grey literature and trial registries. We manually searched topic specific journals, reference and citations of included studies, and reference lists of existing reviews. We extracted data and conducted a risk of bias assessment on the included studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist. We used a narrative synthesis to present the results. Results: Sixteen studies met the inclusion criteria: these explored accelerometers (n = 3) and parental reported tools (n = 13; nine questionnaires, six diaries). Studies assessed construct validity (n = 3), criterion validity (n = 1), convergent validity (n = 13), test-retest reliability (n = 2), internal consistency (n = 4) and feasibility (n = 12). Most studies assessed the convergent validity of questionnaires and diaries compared with accelerometers, but the validity of accelerometers for sleep in this age group is unknown. Of studies with a low risk of bias, one sleep diary was shown to be valid for measuring sleep duration. No measurement tools were appropriate for determining sleep quality. Reporting of reliability and feasibility was minimal. Discussion: The evidence base in this field is limited, and most studies had high risk of bias. Future research on sleep in pre-school aged children should focus on assessing the validity, reliability and feasibility of accelerometers, which in turn will improve the quality of studies that assess questionnaires and diaries against accelerometers. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021230900; PROSPERO: CRD42021230900.