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Hash JB, Walker AJ, Ward TM, Oxford ML, Spieker SJ. Trying to Do What's Best: Maternal Perspectives About Toddler Sleep Health Among an Underresourced Sample of Mothers With Diverse Racial and Ethnic Identities. J Pediatr Health Care 2024; 38:160-171. [PMID: 38429028 PMCID: PMC10987074 DOI: 10.1016/j.pedhc.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/29/2023] [Accepted: 12/03/2023] [Indexed: 03/03/2024]
Abstract
INTRODUCTION This study describes mothers' knowledge, attitudes, beliefs, and practices about their toddler's sleep health among an underresourced sample of mothers with diverse racial and ethnic identities. METHOD This was a descriptive qualitative study with 16 mothers and their 12- to 36-month-old child. Mothers completed a semistructured, audio-recorded interview about their toddler's sleep health. Data were analyzed using inductive content analysis on the basis of established methods. RESULTS Mothers self-identified as 18.8% Black, 43.8% White, 12.5% multiracial, 25.0% other race, and 37.5% Hispanic. Of the mothers, 80.0% reported a past year household income of ≤ $40,000. A core construct, "Trying to do What's Best," emerged from the interview data, and this construct included three domains: Getting Good Sleep, Getting Thrown Off, and Rolling With It. DISCUSSION Findings support future strengths-based and multilevel sleep health-promoting interventions.
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Mistry MS, Gauvreau K, Alexander ME, Jenkins K, Gauthier N. Socioeconomic Factors Influencing Pediatric Peak Oxygen Consumption Prediction. J Pediatr 2024; 264:113742. [PMID: 37730107 DOI: 10.1016/j.jpeds.2023.113742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/04/2023] [Accepted: 09/13/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE To determine if socioeconomic status (SES) has a greater effect than standard demographic values on predicted peak oxygen consumption (pVO2). STUDY DESIGN We conducted a single-institution, retrospective analysis of maximal cardiopulmonary exercise test (CPET) data from 2010 to 2020 for healthy patients age <19 years with body mass index (BMI) percentile (BMI%) between 5-95. Data were sorted by self-identified race, BMI%, and adjusted gross income (AGI); AGI served as a surrogate for SES. Mean percent predicted pVO2 (pppVO2) was compared between groups. Linear regression was used to adjust for differences. RESULTS A total of 541 CPETs met inclusion criteria. Mean pppVO2 was 97% ± 22.6 predicted (P < .01) with 30% below criterion standard for normal (85% predicted). After excluding unknown AGI and race, 418 CPETs remained. Mean pppVO2 was lower for Blacks (n = 36) and Latinx (n = 26) compared with Whites (n = 333, P < .01). Mean pppVO2 declined as AGI decreased (P < .01). The differences in pppVO2 between racial categories remained significant when adjusted for BMI% (Black r = -7.3, P = .035; Latinx r = -15.4, P < .01). These differences both decreased in magnitude and were no longer significant when adjusted for AGI (Black r = -6.0, P = .150; Latinx r = -9.3, P = .06). CONCLUSIONS Lower SES correlates with lower measured cardiovascular fitness and may confound data interpretation. When using normative reference ranges in clinical decision making, providers should recognize that social determinants of health may influence predicted fitness. Social inequities should be considered when assessing pediatric cardiovascular fitness.
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Affiliation(s)
- Maanasi S Mistry
- Department of Cardiology, Boston Children's Hospital, Boston, MA.
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Biostatistics, Harvard T. Chan School of Public Health, Boston, MA
| | - Mark E Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Kathy Jenkins
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Naomi Gauthier
- Department of Cardiology, Boston Children's Hospital, Boston, MA
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Ordway MR, Sadler LS, Jeon S, Pierre JC, Canapari C, Redeker NS. Early emergence of racial and ethnic differences in sleep health among toddlers living in low-income families. Sleep Health 2023; 9:389-397. [PMID: 37453903 PMCID: PMC10517059 DOI: 10.1016/j.sleh.2023.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 01/08/2023] [Accepted: 02/22/2023] [Indexed: 07/18/2023]
Abstract
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.
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Affiliation(s)
- Monica R Ordway
- Yale School of Medicine, Department of Pediatrics, New Haven, Connecticut, USA; Yale School of Nursing, West Haven, Connecticut, USA.
| | - Lois S Sadler
- Yale School of Nursing and Yale Child Study Center, West Haven, Connecticut, USA
| | | | - Jasmyne C Pierre
- Yale University, Department of Psychology, New Haven, Connecticut, USA
| | - Craig Canapari
- Yale School of Medicine, Department of Pediatrics, New Haven, Connecticut, USA
| | - Nancy S Redeker
- University of Connecticut School of Nursing, Storrs, Connecticut, USA
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Levenson JC, Williamson AA. Bridging the gap: leveraging implementation science to advance pediatric behavioral sleep interventions. J Clin Sleep Med 2023; 19:1321-1336. [PMID: 36722616 PMCID: PMC10315605 DOI: 10.5664/jcsm.10476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 02/02/2023]
Abstract
STUDY OBJECTIVES This review synthesizes the pediatric behavioral sleep intervention (BSI) evidence base, summarizes challenges in translating BSIs from research to practice, and provides recommendations for integrating implementation science methods to advance pediatric BSI research. METHODS We briefly review the common behavioral sleep disturbances among youth, discuss the pediatric BSIs with well-established evidence, and identify gaps in pediatric BSI research. We then identify contributors to the dearth of research evaluating pediatric BSIs in accessible settings and present a model for applying implementation science strategies to address identified gaps across the continuum of translational research. RESULTS Relatively few BSI trials include older children and adolescents. Similarly, there is limited research evaluating BSIs among racially and ethnically minoritized children and families and/or those of lower socioeconomic status backgrounds. Access to scalable and easily disseminable tools to treat pediatric sleep disturbances early in their development is crucial for promoting positive child outcomes. To address these gaps, researchers should apply implementation science theories, models, and frameworks to design new interventions for implementation, adapt existing interventions with end users and settings in mind, conduct hybrid effectiveness-implementation trials, and test implementation strategies. CONCLUSIONS Given the prevalence and consequences of poor sleep across developmental periods, pediatric BSIs must be effective as well as adaptable, scalable, and easily disseminable. Implementation science theories, models, and frameworks can enhance access to, engagement in, and the implementation and dissemination of scalable BSIs across diverse pediatric care settings and heterogeneous populations. CITATION Levenson JC, Williamson AA. Bridging the gap: leveraging implementation science to advance pediatric behavioral sleep interventions. J Clin Sleep Med. 2023;19(7):1321-1336.
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Affiliation(s)
- Jessica C. Levenson
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ariel A. Williamson
- Sleep Center, Division of Pulmonary and Sleep Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Psychiatry, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
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Lupini F, Williamson AA. Health Disparities in Pediatric Sleep. Sleep Med Clin 2023; 18:225-234. [PMID: 37120165 PMCID: PMC10210975 DOI: 10.1016/j.jsmc.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
This article reviews disparities in pediatric sleep health and sleep disorders from early childhood through adolescence (birth to age 18 years). Sleep health is a multidimensional construct including sleep duration, consolidation, and other domains, whereas sleep disorders reflect both behaviorally (eg, insomnia) and medically based (eg, sleep disordered breathing) sleep diagnoses. Using a socioecological framework, we review multilevel (ie, child, family, school, health-care system, neighborhood, and sociocultural) factors linked to sleep health disparities. Mechanistic research and studies using an intersectional lens to understand overlapping marginalized identities are needed to inform multilevel interventions to promote sleep health equity in pediatrics.
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Affiliation(s)
- Francesca Lupini
- Children's National Hospital, 111 Michigan Avenue Northwest, 6 Floor CTR Suite, Room M7658, Washington, DC 20010, USA
| | - Ariel A Williamson
- Children's Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street Boulevard, Room 8202, Philadelphia, PA 19146, USA; University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA.
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Kahn M, Barnett N, Gradisar M. Implementation of Behavioral Interventions for Infant Sleep Problems in Real-World Settings. J Pediatr 2023; 255:137-146.e2. [PMID: 36375604 DOI: 10.1016/j.jpeds.2022.10.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 10/08/2022] [Accepted: 10/11/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To compare the real-world frequency, timing, duration, difficulty, and helpfulness of 3 infant Behavioral Sleep Intervention (BSI) approaches: Unmodified Extinction, Modified Extinction, and Parental Presence and to examine the effectiveness and safety of these approaches by comparing infant sleep, parent sleep, daytime sleepiness, depression, and parent-infant bonding between parents who had and had not implemented these interventions. STUDY DESIGN Participants were 2090 parents (75% mothers, 79% White/Caucasian) of US infants (49% girls) aged 3-18 months (M = 9.1, SD = 4.1). Parents completed online questionnaires regarding their infant's sleep, their own sleep, daytime sleepiness, depression levels, and parent-infant bonding. Infant sleep was assessed via objective-albeit exploratory-autovideosomnography data obtained from the 14 days prior to survey completion. RESULTS Sixty-four percent of parents reported implementing BSIs. The average age at intervention was 5.3 months (SD = 2.6). Unmodified and Modified Extinction were rated as significantly more difficult to implement compared with Parental Presence but also as more helpful, shorter, and quicker to show improvements. Infant nighttime sleep was longer and more consolidated in the Unmodified and Modified Extinction groups compared with the Parental Presence and non-BSI groups. No differences were found between BSI groups in parent sleep, sleepiness, depression, or parent-infant bonding. CONCLUSIONS Implementation of BSIs outside clinical settings is pervasive and occurs earlier than generally recommended. Unmodified and Modified Extinction were associated with longer and more consolidated infant sleep. Despite concerns regarding the potential harm of BSIs, implementation of these approaches was not linked with negative outcomes, providing additional evidence for their safety and effectiveness.
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Affiliation(s)
- Michal Kahn
- College of Education, Psychology and Social Work, Flinders University, Adelaide, South Australia, Australia.
| | | | - Michael Gradisar
- Wink Sleep Pty Ltd, Adelaide, South Australia, Australia; Sleep Cycle AB, Gothenburg, Sweden
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Honaker SM, Chung A. Infant Behavioral Sleep Intervention in Black Families. JAMA Netw Open 2023; 6:e236286. [PMID: 37000455 DOI: 10.1001/jamanetworkopen.2023.6286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Affiliation(s)
- Sarah M Honaker
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Alicia Chung
- Center for Early Childhood Health and Development, Department of Population Health, New York University Grossman School of Medicine, New York
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Adams EL, Edgar A, Mosher P, Armstrong B, Burkart S, Weaver RG, Beets MW, Siceloff ER, Prinz RJ. Barriers to Optimal Child Sleep among Families with Low Income: A Mixed-Methods Study to Inform Intervention Development. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:862. [PMID: 36613199 PMCID: PMC9820071 DOI: 10.3390/ijerph20010862] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/20/2022] [Accepted: 12/27/2022] [Indexed: 06/17/2023]
Abstract
This study gathered formative data on barriers to optimal child sleep to inform the development of a sleep intervention for parents of preschool-aged children in low-income households. Parents (n = 15, age: 34 ± 8 years, household income: $30,000 ± 17,845/year) reporting difficulties with their child's sleep participated in this study. Mixed methods included an online survey and semi-structured phone interview. Items assessed barriers/facilitators to optimal child sleep and intervention preferences. Interview transcripts were coded using inductive analyses and constant-comparison methods to generate themes. Derived themes were then mapped onto the Theoretical Domains Framework to contextualize barriers and inform future intervention strategies. Themes that emerged included: stimulating bedtime activities, child behavior challenges, variability in children's structure, parent work responsibilities, sleep-hindering environment, and parent's emotional capacity. Parent's intervention preferences included virtual delivery (preferred by 60% of parents) to reduce barriers and provide flexibility. Mixed preferences were observed for the group (47%) vs. individual (53%) intervention sessions. Parents felt motivated to try new intervention strategies given current frustrations, the potential for tangible results, and knowing others were in a similar situation. Future work will map perceived barriers to behavior change strategies using the Behavior Change Wheel framework to develop a parenting sleep intervention.
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Affiliation(s)
- Elizabeth L. Adams
- Department of Exercise Science, University of South Carolina, 921 Assembly Street, Columbia, SC 29208, USA
- Research Center for Child Well-Being, University of South Carolina, 1400 Pickens Street, Suite 400, Columbia, SC 29201, USA
| | - Amanda Edgar
- Research Center for Child Well-Being, University of South Carolina, 1400 Pickens Street, Suite 400, Columbia, SC 29201, USA
| | - Peyton Mosher
- Department of Exercise Science, University of South Carolina, 921 Assembly Street, Columbia, SC 29208, USA
| | - Bridget Armstrong
- Department of Exercise Science, University of South Carolina, 921 Assembly Street, Columbia, SC 29208, USA
- Research Center for Child Well-Being, University of South Carolina, 1400 Pickens Street, Suite 400, Columbia, SC 29201, USA
| | - Sarah Burkart
- Department of Exercise Science, University of South Carolina, 921 Assembly Street, Columbia, SC 29208, USA
- Research Center for Child Well-Being, University of South Carolina, 1400 Pickens Street, Suite 400, Columbia, SC 29201, USA
| | - R. Glenn Weaver
- Department of Exercise Science, University of South Carolina, 921 Assembly Street, Columbia, SC 29208, USA
- Research Center for Child Well-Being, University of South Carolina, 1400 Pickens Street, Suite 400, Columbia, SC 29201, USA
| | - Michael W. Beets
- Department of Exercise Science, University of South Carolina, 921 Assembly Street, Columbia, SC 29208, USA
- Research Center for Child Well-Being, University of South Carolina, 1400 Pickens Street, Suite 400, Columbia, SC 29201, USA
| | - E. Rebekah Siceloff
- Research Center for Child Well-Being, University of South Carolina, 1400 Pickens Street, Suite 400, Columbia, SC 29201, USA
| | - Ronald J. Prinz
- Research Center for Child Well-Being, University of South Carolina, 1400 Pickens Street, Suite 400, Columbia, SC 29201, USA
- Department of Psychology, Barnwell College, University of South Carolina, 1512 Pendleton Street, Columbia, SC 29208, USA
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Hughes AJ, Gunn H, Siengsukon C, Stearns MA, James E, Donley T, Grandner MA, Thomas SJ, Hansen K, Williams NJ. Eliminating Sleep Health Disparities and Achieving Health Equity: Seven Areas for Action in the Behavioral Sleep Medicine Community. Behav Sleep Med 2022:1-13. [PMID: 36573844 DOI: 10.1080/15402002.2022.2149523] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Racial and ethnically minoritized and under-resourced populations do not reap the same benefits of sufficient sleep as their white counterparts resulting in insufficient sleep and sleep health disparities. Research exploring these disparities have documented a plethora of factors including social determinants of health, community violence, and structural issues - all of which are associated with adverse sleep. There are robust evidence base behavioral intervention that can be leveraged to improve sleep health among racial and ethnic groups. However, EBIs are not well leveraged. In 2021, with participation from members of the society of behavioral sleep medicine, we conducted this report to bring together the field of behavioral sleep medicine including researchers, clinicians and trainees to discuss gaps and opportunities at the intersection of the COVID-19 pandemic, systemic racism, and sleep health. The goals were anchored around seven recommendations toward reducing disparities in the near-term and longer-term approaches to eliminating disparities. Furthermore, we acknowledge that reducing and eliminating disparities in sleep health requires a multifaceted approach that includes a focus on individual, community, health care and societal levels of influence with participation from diverse partners including federal, state and local.
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Affiliation(s)
- Abbey J Hughes
- School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Heather Gunn
- Department of Psychology, University of Alabama College Store, Tuscaloosa, Alabama, USA
| | - Catherine Siengsukon
- Health and Wellness Lab, University of Kansas Medical Center School of Health Professions, Kansas City, Missouri, USA
| | - Melanie A Stearns
- Department of Psychiatry, University of Missouri, Columbia, Missouri, USA
| | - Elisabeth James
- Sleep Medicine Services, The University of Toledo, Toledo, Ohio, USA
| | - Tiffany Donley
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Michael A Grandner
- Department of Psychiatry, The University of Arizona Department of Neuroscience, Tucson, Arizona, USA
| | - S Justin Thomas
- Department of Psychiatry and Behavioral Neurobiology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kathryn Hansen
- Society of Behavioral Sleep Medicine, National Office, Lexington, Kentucky, USA
| | - Natasha J Williams
- Institue for Excellence in Health Equity, Department of Population Health, NYU Grossman School of Medicine
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Sansavini A, Riva M, Zuccarini M, Aceti A, Corvaglia L, Scher A, Guarini A. Night Sleep and Parental Bedtime Practices in Low-Risk Preterm and Full-Term Late Talkers. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121813. [PMID: 36553255 PMCID: PMC9777501 DOI: 10.3390/children9121813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/14/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022]
Abstract
Night sleep and parental bedtime practices have rarely been investigated in late talkers. This study aimed to explore: night sleep, parental bedtime practices, and their associations in late talkers as well as individual, socio-demographic, and socio-relational factors affecting them. Parents of 47 30-month-old late talkers, born low-risk preterm (n = 24) or full-term (n = 23), with an expressive vocabulary size ≤10th percentile measured by the MacArthur-Bates Communicative Development Inventory Words and Sentences, and normal cognitive abilities measured by the Bayley Scales, completed the Infant Sleep Questionnaire, the Parental Interactive Bedtime Behaviour Scale, and the Parenting Stress Index Short Form. Results showed slight settling difficulties, night wakings, and frequent co-sleeping in late talkers. Encouraging autonomy practices were frequently used by parents, rather than active physical comforting ones. Recurrent settling difficulties were reported by parents who often applied encouraging autonomy practices, whereas greater night waking problems and frequent co-sleeping were reported by parents who often left their child crying. Low-risk preterm birth and mother's parenting stress predicted total sleep difficulties and night wakings; first-born, high maternal education level and mother's parenting stress predicted settling difficulties; mother's parenting stress was the only predictor for co-sleeping and leaving to cry. These findings have relevant implications for improving late talkers' night sleep and their parents' bedtime practices.
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Affiliation(s)
- Alessandra Sansavini
- Department of Psychology “Renzo Canestrari”, University of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy
- Correspondence:
| | - Martina Riva
- Department of Psychology “Renzo Canestrari”, University of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy
| | - Mariagrazia Zuccarini
- Department of Education Studies “Giovanni Maria Bertin”, University of Bologna, Via Filippo Re 6, 40126 Bologna, Italy
| | - Arianna Aceti
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria Bologna, Via Massarenti 9, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria Bologna, Via Massarenti 9, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
| | - Anat Scher
- Department of Counseling and Human Development, University of Haifa, Abba Khoushy Ave 199, Haifa 3498838, Israel
| | - Annalisa Guarini
- Department of Psychology “Renzo Canestrari”, University of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy
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Williamson AA, Soehner AM, Boyd RC, Buysse DJ, Harvey AG, Jonassaint CR, Franzen PL, Goldstein TR. A protocol for applying health equity-informed implementation science models and frameworks to adapt a sleep intervention for adolescents at risk for suicidal thoughts and behaviors. Front Public Health 2022; 10:971754. [PMID: 36311565 PMCID: PMC9597692 DOI: 10.3389/fpubh.2022.971754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/16/2022] [Indexed: 01/25/2023] Open
Abstract
Background Effective and equitable strategies to prevent youth suicidal thoughts and behaviors (STB) are an urgent public health priority. Adolescent sleep disturbances are robustly linked to STB but are rarely addressed in preventive interventions or among Black and/or Hispanic/Latinx youth for whom STB risk is increasing disproportionately. This paper describes an application of health equity-informed implementation science models and frameworks to adapt and evaluate the evidence-based Transdiagnostic Sleep and Circadian (TSC) intervention for primary care implementation with adolescents of minoritized backgrounds with depression and STB risk. Methods This multiphase study protocol uses the Assessment, Decision, Adaptation, Production, Topical Experts-Integration, Training, Testing (ADAPT-ITT) model to adapt and evaluate TSC for primary care implementation with adolescents who are depressed, at risk for STB, and of primarily Black and/or Hispanic/Latinx backgrounds. We integrate the Consolidated Framework for Implementation Research (CFIR) in an initial qualitative inquiry of adolescent, caregiver, and clinician perceptions of TSC. Subsequent ADAPT-ITT phases include systematically and iteratively testing adaptations based on the qualitative inquiry, with ongoing key informant input, and then evaluating the adapted TSC for feasibility, acceptability, and efficacy in a pilot randomized trial. Anticipated results Based on youth depression and sleep health disparities research, we expect that TSC adaptations will be needed to enhance intervention content for adolescents with depression, STB risk, and primarily Black and/or Hispanic/Latinx backgrounds. We also anticipate adaptations will be needed to align TSC delivery methods with primary care implementation. Conclusions Adapting evidence-based interventions with end-users and contexts in mind can help ensure that intervention strategies and delivery methods are acceptable to, and feasible with, health disparate populations. Although TSC has shown effectiveness for adolescents with sleep disturbances, we expect that additional multiphase research is necessary to optimize TSC for primary care delivery with Black and/or Hispanic/Latinx adolescents with depression and STB risk.
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Affiliation(s)
- Ariel A. Williamson
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, United States,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States,*Correspondence: Ariel A. Williamson
| | - Adriane M. Soehner
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Rhonda C. Boyd
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, United States,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Daniel J. Buysse
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Allison G. Harvey
- Department of Psychology, University of California, Berkeley, Berkeley, CA, United States
| | - Charles R. Jonassaint
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Peter L. Franzen
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tina R. Goldstein
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Bonuck K, Collins-Anderson A, Schechter CB, Felt BT, Chervin RD. Effects of a Sleep Health Education Program for Children and Parents on Child Sleep Duration and Difficulties: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2223692. [PMID: 35881396 PMCID: PMC9327577 DOI: 10.1001/jamanetworkopen.2022.23692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
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.
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Affiliation(s)
- Karen Bonuck
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | | | - Clyde B. Schechter
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | | | - Ronald D. Chervin
- Sleep Disorders Center, University of Michigan, Ann Arbor
- Department of Neurology, University of Michigan, Ann Arbor
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13
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Abstract
There is growing public health concern about the high prevalence of sleep deficiency in early childhood and the associated risk for sleep-associated poor health outcomes, including metabolic, cardiovascular, and mental health. The recent shift to conceptualize sleep health as a multidimensional construct, influenced by socioecological factors, highlights the potential role of sleep in health disparities. Understanding the development of sleep health and the emergence of sleep disorders in early life is a current priority in pediatric sleep research. Future behavioral sleep interventions should consider the multiple socioecological influences on children's sleep health and be tested using inclusive sampling methods.
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Affiliation(s)
| | - Sarah Logan
- Yale School of Nursing, PO Box 27399, West Haven, CT 06516-7399, USA
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14
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Pavkovic IM, Kothare SV. Pharmacologic Approaches to Insomnia and Other Sleep Disorders in Children. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00712-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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15
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Williamson AA, Okoroji C, Cicalese O, Evans BC, Ayala A, Harvey B, Honore R, Kratchman A, Beidas RS, Fiks AG, Power TJ, Mindell JA. Sleep Well! An adapted behavioral sleep intervention implemented in urban primary care. J Clin Sleep Med 2022; 18:1153-1166. [PMID: 34910624 PMCID: PMC8974371 DOI: 10.5664/jcsm.9822] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To describe the adaptation, feasibility, and initial outcomes of Sleep Well!, an intervention for early childhood insomnia and insufficient sleep, designed for families from lower-socioeconomic status backgrounds presenting to large metropolitan primary care sites. METHODS Fifteen caregiver-child dyads (caregivers: 92.3% mothers, 80.0% Black, 53.3% ≤ 125% US poverty level; children: 73.3% female, 86.7% Black, mean age = 3.0 years) participated in this multimethod, single-arm trial. A family advisory board of caregivers (n = 4) and a clinician advisory board of sleep experts, primary care clinicians, and psychologists (n = 13) provided intervention feedback throughout the pilot. Most adaptations were related to intervention delivery methods, with some related to sleep strategies. At postintervention, caregivers completed surveys on intervention acceptability and cultural humility (primary outcomes) and completed semistructured interviews. Caregivers also reported on child sleep pre- and postintervention. RESULTS Thirteen (86.6%) families completed Sleep Well! and 12 (80.0%) completed pre- and postintervention measures. Caregivers reported strong intervention acceptability and cultural humility. There were preintervention to postintervention reductions in child sleep problems, bedroom electronics, sleep onset latency, and night awakening frequency and duration. Nighttime sleep duration and overall insufficient sleep also improved. Qualitative data also showed strong intervention acceptability and perceived flexibility, with few participation barriers. CONCLUSIONS A brief, early childhood behavioral sleep intervention delivered in primary care with families from primarily lower-socioeconomic status backgrounds and/or racially minoritized backgrounds is feasible to implement, with strong retention rates, acceptability, and perceptions of cultural humility. Child sleep improvements are positive and warrant replication in a randomized controlled trial. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Implementing Behavioral Sleep Intervention in Urban Primary Care; URL: https://clinicaltrials.gov/ct2/show/NCT04046341; Identifier: NCT04046341. CITATION Williamson AA, Okoroji C, Cicalese O, et al. Sleep Well! An adapted behavioral sleep intervention implemented in urban primary care. J Clin Sleep Med. 2022;18(4):1153-1166.
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Affiliation(s)
- Ariel A. Williamson
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Olivia Cicalese
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Amanda Ayala
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bethany Harvey
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rachel Honore
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amy Kratchman
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rinad S. Beidas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Alexander G. Fiks
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas J. Power
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jodi A. Mindell
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Saint Joseph’s University, Philadelphia, Pennsylvania
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16
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Lobermeier M, Staples AD, Peterson C, Huth-Bocks AC, Warschausky S, Taylor HG, Brooks J, Lukomski A, Lajiness-O'Neill R. Cumulative risk, infant sleep, and infant social-emotional development. Infant Behav Dev 2022; 67:101713. [PMID: 35339929 PMCID: PMC9526438 DOI: 10.1016/j.infbeh.2022.101713] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 11/17/2022]
Abstract
The effect of cumulative biological, psychosocial, and demographic risk and infant sleep on infant social-emotional functioning in 12-month-old infants (46% female) was examined in data from racially (30% Black, 60% White, 10% multiracial/other) and socioeconomically (41% below median income) diverse caregivers (N = 468, M = 30.42 years old, SD = 5.65) recruited from two midwestern states in 2019-2020. Due to the major changes in sleep patterns during infancy and the reported association between sleep and social-emotional functioning, this study also examined whether sleep moderates the association between risk and infant social-emotional functioning and potentially promotes healthy social-emotional functioning despite risk. Greater cumulative risk was associated with poorer sleep efficiency and more social-emotional problems, but was not associated with the general acquisition of social-emotional milestones. Results also suggested that poorer sleep efficiency was associated with more social-emotional problems and poorer social-emotional milestone acquisition. No significant interaction effects were found between cumulative risk and infant sleep. Risk and sleep appear to have unique associations with infant social-emotional problems and development; thus both could be targeted in early intervention to promote social-emotional functioning during infancy and early childhood.
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Affiliation(s)
| | - Angela D Staples
- Eastern Michigan University, Department of Psychology, Ypsilanti, MI, USA
| | - Catherine Peterson
- Eastern Michigan University, Department of Psychology, Ypsilanti, MI, USA
| | - Alissa C Huth-Bocks
- University Hospitals Cleveland Medical Center, Pediatrics, Cleveland, OH, USA; Case Western Reserve University and Rainbow Babies & Children's Hospital, Department of Pediatrics, Cleveland, Ohio, USA
| | - Seth Warschausky
- University of Michigan, Michigan Medicine, Department of Physical Medicine and Rehabilitation, Ann Arbor, Michigan, USA
| | - H Gerry Taylor
- Case Western Reserve University and Rainbow Babies & Children's Hospital, Department of Pediatrics, Cleveland, Ohio, USA; Nationwide Children's Hospital Research Institute and The Ohio State University, Department of Pediatrics, Columbus, Ohio, USA
| | - Judith Brooks
- Eastern Michigan University, School of Health Sciences, Dietetics and Human Nutrition Programs, Ypsilanti, MI, USA
| | - Angela Lukomski
- Eastern Michigan University, School of Nursing, Ypsilanti, Michigan, USA
| | - Renée Lajiness-O'Neill
- Eastern Michigan University, Department of Psychology, Ypsilanti, MI, USA; University of Michigan, Michigan Medicine, Department of Physical Medicine and Rehabilitation, Ann Arbor, Michigan, USA.
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17
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Clarke A, Fiorvanti C. Meeting families where they sleep: a collaborative approach to improving sleep health for urban children. J Clin Sleep Med 2022; 18:971-972. [PMID: 35356861 PMCID: PMC8974387 DOI: 10.5664/jcsm.9932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Allison Clarke
- Pritzker Department Psychiatry and Behavioral Health, Department of Sleep Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Christina Fiorvanti
- Pediatric Behavioral Health Integration Program, HealthySteps Program, Department of Pediatrics, Montefiore Medical Center, Bronx, NY
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18
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Blunden S, Osborne J, King Y. Do responsive sleep interventions impact mental health in mother/infant dyads compared to extinction interventions? A pilot study. Arch Womens Ment Health 2022; 25:621-631. [PMID: 35380237 PMCID: PMC9072263 DOI: 10.1007/s00737-022-01224-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
Methods to improve sleep in infants commonly involve some ignoring (extinction) but are often unpopular with mothers worried about infant distress when left to cry. Alternative more responsive methods are needed. This pilot study evaluated stress, maternal depressive symptomology and sleep in mother/infant dyads, between Responsive, Controlled Crying and Control groups. From 199 mother/infant dyads from any cultural background, 41 infants 4-12 months were randomly allocated to Responsive (RG, n = 15), Controlled Crying (CCG, n = 18) or Controls (Treatment as Usual, TAUG, n = 8), with 10 withdrawing after randomisation. Infant sleep (7-day sleep diaries) and stress (oral cortisol on two nights), maternal self-reported stress (Subjective Units of Distress, SUDS), maternal perceived infant distress (MPI-S) and symptoms of maternal depression (Edinburgh Post-natal Depression Scale, EPDS) were measured four times across 8 weeks. Sleep duration was not different between groups but Responsive woke less (p = .008). There were no differences in cortisol between groups across time points. Maternal SUDS was positively correlated with infant cortisol and MPI-S (p < 0.05) and mothers in the Responsive group were significantly less stressed (p = 0.02) and reported less symptoms of depression (p < 0.05). Findings in this small sample show Responsive methods are comparable to the extinction (Controlled Crying) in sleep outcomes but from a relational and maternal mental health perspective, are less stressful, offering families potential choices of sleep interventions.
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Affiliation(s)
- Sarah Blunden
- Appleton Institute, Central Queensland University, 44 Greenhill Rd, South Australia, Wayville, 5034, Australia.
| | - Joanne Osborne
- Appleton Institute, Central Queensland University, 44 Greenhill Rd, South Australia Wayville, 5034 Australia
| | - Yaroslava King
- Appleton Institute, Central Queensland University, 44 Greenhill Rd, South Australia Wayville, 5034 Australia
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19
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Bucko AG, Dowda M, Frongillo EA, Torres ME, Pate RR. Nighttime sleep and physical activity in 6-7 month-old infants. Infant Behav Dev 2021; 65:101628. [PMID: 34392076 PMCID: PMC8627435 DOI: 10.1016/j.infbeh.2021.101628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 11/16/2022]
Abstract
This study examined associations between objectively-measured nighttime sleep duration and physical activity in a sample of 6-7 month-old infants (N=93). The study also investigated relationships between infant sleep and demographic and environmental characteristics. Cross-sectional relationships were assessed using linear regression analyses. Nighttime sleep duration was positively associated with physical activity levels. Nighttime sleep duration was greater when infants had a consistent bedtime, slept in a separate room, were male, and had mothers who reported having a college education or greater. These findings can inform the development of interventions that aim to improve infant sleep.
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Affiliation(s)
- Agnes G Bucko
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States.
| | - Marsha Dowda
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Edward A Frongillo
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Myriam E Torres
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Russell R Pate
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
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20
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Egbegi DR, Bella-Awusah T, Omigbodun O, Ani C. A controlled trial of Cognitive Behavioural Therapy-based strategies for insomnia among in-school adolescents in southern Nigeria. Child Adolesc Psychiatry Ment Health 2021; 15:52. [PMID: 34563220 PMCID: PMC8465787 DOI: 10.1186/s13034-021-00406-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/16/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Sleep difficulties are highly prevalent among adolescents, and are associated with significant impairments. The effectiveness and acceptability of Cognitive Behavioural Therapy-based (CBT-based) treatment for insomnia in adolescents is established for High Income Countries, but unknown for African settings. Thus, the aim of this study was to assess the effect of CBT-based intervention among in-school adolescents with sleep difficulties in Southern Nigeria. METHODS This was a pilot controlled trial involving 50 adolescents with highest ranked scores on the Insomnia Severity Index (ISI) recruited from four schools (two government and two privately owned). Balloting was used to assign two schools (public and private) with 25 participants to the intervention group, and the other two schools (public and private) with 25 participants as waiting-list controls. The two groups were dyad-matched for baseline ISI scores, gender, and type of school to reduce baseline differences. The treatment group received weekly group-based manualised CBT-based intervention over 5 weeks. Primary outcome was ISI score at 6th week. Secondary outcomes were sleep onset latency (SOL), Total sleep duration (TSD), depressive symptoms, sleep hygiene, and knowledge about sleep. RESULTS Participants were aged 13-17 years (M = 14.9, SD = 1.16) and consisted of 18 males and 32 females. Controlling for baseline scores, the intervention group showed significantly lower post-intervention insomnia scores compared with the control group {F (1, 34) = 1.10, p = 0.0001, (ηp2 = 0.59}, shorter SOL {F (1, 33) = 1.41, p = 0.0001, ηp2 = 0.39}, longer TSD {F (1, 33) = 1.03, p = 0.0001, ηp2 = 0.47}, lower depressive symptoms {F (1, 31) = 1.32, p = 0.002 (ηp2 = 0.34}, higher knowledge of sleep {F (1, 34) = 1.02, p = 0.001, ηp2 = 0.36}, but no significant change in sleep hygiene {F (1, 32) = 1.08, p = 0.08, ηp2 = 0.15}. All participants in the intervention group rated the programme as good or excellent. CONCLUSION This pilot CBT-based intervention for adolescents with insomnia was feasible, well received and showed promising efficacy in this setting. Larger controlled trials are recommended to establish the generalisability of these findings in this region. Trial registration Pan African Clinical Trial Registry (Registration Number PACTR202001710494962).
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Affiliation(s)
- Diseyei R. Egbegi
- grid.9582.60000 0004 1794 5983Centre for Child and Adolescent Mental Health, University of Ibadan, Ibadan, Nigeria
| | - Tolulope Bella-Awusah
- grid.9582.60000 0004 1794 5983Centre for Child and Adolescent Mental Health, University of Ibadan, Ibadan, Nigeria ,grid.9582.60000 0004 1794 5983Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Olayinka Omigbodun
- grid.9582.60000 0004 1794 5983Centre for Child and Adolescent Mental Health, University of Ibadan, Ibadan, Nigeria ,grid.9582.60000 0004 1794 5983Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Cornelius Ani
- Division of Psychiatry, Imperial College London, Hammersmith Hospital Campus, 2nd Floor Commonwealth Building, Du Cane Road, London, W12 0NN, UK. .,Surrey and Borders Partnership, NHS Foundation Trust, Leatherhead, Surrey, UK.
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21
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Honaker SM, McQuillan ME, Mindell JA, Downs SM, Slaven JE, Schwichtenberg AJ. Screening for Problematic Sleep in a Diverse Sample of Infants. J Pediatr Psychol 2021; 46:824-834. [PMID: 34283243 PMCID: PMC8357224 DOI: 10.1093/jpepsy/jsab050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 03/28/2021] [Accepted: 04/22/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To examine screening strategies for identifying problematic sleep in a diverse sample of infants. METHODS Parents of infants (5-19 months; N = 3,271) presenting for a primary care visit responded to five screening items and the Infant Sleep Questionnaire (ISQ), a validated measure of problematic infant sleep. If parents responded affirmatively to any screening item, primary care providers received a prompt to evaluate. For each of the screening questions, we examined differences in item endorsement and criterion related validity with the ISQ. Using conceptual composites of night waking and sleep difficulty, prevalence, criterion-related validity, and concurrent demographic correlates were analyzed. RESULTS Infants were primarily of Black race (50.1%) or Hispanic ethnicity (31.7%), with the majority (63.3%) living in economically distressed communities. Rates of problematic sleep ranged from 7.4%, for a single item assessing parental perception of an infant having a sleep problem, to 74.0%, for a single item assessing night wakings requiring adult intervention. Items assessing sleep difficulty had high (95.0-97.8%) agreement with the ISQ in identifying infants without problematic sleep, but low agreement (24.9-34.0%) in identifying those with problematic sleep. The opposite was true for items assessing night waking, which identified 91.0-94.6% of those with sleep problems but only 31.8-46.9% of those without. CONCLUSIONS Screening strategies for identifying problematic infant sleep yielded highly variable prevalence rates and associated factors, depending on whether the strategy emphasized parent-perceived sleep difficulty or night wakings. The strategy that is most appropriate will depend on the system's goals.
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Affiliation(s)
- Sarah M Honaker
- Department of Pediatrics, Indiana University School of Medicine
| | | | - Jodi A Mindell
- Department of Psychology, Saint Joseph’s University
- Children’s Hospital of Philadelphia
| | | | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine
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22
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Hoyniak CP, McQuillan MM, Bates JE, Staples AD, Schwichtenberg A, Honaker SM. Presleep Arousal and Sleep in Early Childhood. J Genet Psychol 2021; 182:236-251. [PMID: 33870880 PMCID: PMC8684049 DOI: 10.1080/00221325.2021.1905596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/26/2021] [Indexed: 10/21/2022]
Abstract
Research suggests that arousal during the transition to sleep-presleep arousal-is associated with sleep disturbances. Although a robust literature has examined the role of presleep arousal in conferring risk for sleep disturbances in adults, substantially less research has examined the developmental origins of presleep arousal in early childhood. The authors examined presleep arousal using parent report and psychophysiological measures in a sample of preschoolers to explore the association between different measures of presleep arousal, and to examine how nightly presleep arousal is associated with sleep. Participants included 29 children assessed at 54 months of age. Presleep arousal was measured using parent reports of child arousal each night at bedtime and using a wearable device that took minute-by-minute recordings of heart rate, peripheral skin temperature, and electrodermal activity each night during the child's bedtime routine. This yielded a dataset with 4,550 min of ambulatory recordings across an average of 3.52 nights per child (SD = 1.84 nights per child; range = 1-8 nights). Sleep was estimated using actigraphy. Findings demonstrated an association between parent-reported and psychophysiological arousal, including heart rate, peripheral skin temperature, and skin conductance responses during the child's bedtime routine. Both the parent report and psychophysiological measures of presleep arousal showed some associations with poorer sleep, with the most robust associations occurring between presleep arousal and sleep onset latency. Behavioral and biological measures of hyperarousal at bedtime are associated with poorer sleep in young children. Findings provide early evidence of the utility of wearable devices for assessing individual differences in presleep arousal in early childhood.
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Affiliation(s)
- Caroline P. Hoyniak
- Department of Psychiatry, Washington University in St. Louis School of Medicine, USA
| | | | - John E. Bates
- Department of Psychological and Brain Sciences, Indiana University – Bloomington, USA
| | | | | | - Sarah M. Honaker
- Department of Pediatrics, Indiana University School of Medicine, USA
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23
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Honaker SM, Mindell JA, Slaven JE, Schwichtenberg AJ. Implementation of Infant Behavioral Sleep Intervention in a Diverse Sample of Mothers. Behav Sleep Med 2021; 19:547-561. [PMID: 32954835 DOI: 10.1080/15402002.2020.1817745] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE/BACKGROUND Behavioral Sleep Interventions (BSI) is an efficacious class of treatment approaches for infant sleep disturbance. Little is known about BSI implementation in the real world. Objectives were to a) examine the prevalence of BSI implementation and related factors in a diverse sample of US mothers; b) assess racial-ethnic group differences; and c) examine predictors of BSI implementation. PARTICIPANTS Participants included mothers (n= 353) with an infant (6-18 months) from one of the three racial-ethnic groups: White Hispanic (n= 113), White non-Hispanic (n= 122), Black non-Hispanic (n= 118). METHODS Respondents completed an online survey assessing BSI implementation, familiarity, barriers, sleep knowledge, cognitions, and sleep patterns. RESULTS Approximately one-third (36%) of the sample endorsed BSI implementation and 59% reported BSI familiarity. Black non-Hispanic mothers were more likely to report stopping a BSI prior to completion (OR = 4.92, p <.05) and more likely to hear about BSI from a health-care professional (OR = 1.32, p <.05) compared to White non-Hispanic mothers. Racial-ethnic group differences were identified for a variety of sleep practices, including bedsharing, independent sleep onset, and score on a validated measure of problematic sleep. No racial-ethnic group differences were found in BSI implementation, cognitions, or barriers. BSI implementation was predicted by BSI familiarity, more maternal education, and cognitions around infant self-soothing. CONCLUSIONS Differential BSI implementation does not appear to be a major driver of sleep disparities, although Black non-Hispanic mothers who decide to implement BSI do report notably lower completion rates. Future studies should examine alternative mechanisms of sleep disparities as well as strategies to promote sleep health in diverse families.
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Affiliation(s)
| | - Jodi A Mindell
- Department of Psychology, Saint Joseph's University, Philadelphia, PA, USA
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - James E Slaven
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - A J Schwichtenberg
- Department of Human Development and Family Studies, Purdue University, West Lafayette, Indiana
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Whittall H, Kahn M, Pillion M, Gradisar M. Parents matter: barriers and solutions when implementing behavioural sleep interventions for infant sleep problems. Sleep Med 2021; 84:244-252. [PMID: 34182352 DOI: 10.1016/j.sleep.2021.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Abstract
Behavioural sleep interventions (eg, extinction-based methods) are among the most efficacious evidence-based techniques in the treatment of infant sleep problems. However, behavioural sleep interventions can be challenging for families to successfully implement. This review aims to summarise current research surrounding the potential barriers that arise when clinicians attempt to implement extinction-based methods with parents of infants. We provide a model that summarises 3 types of contextual-barriers; socio-cultural barriers, parent barriers, and infant barriers. Based on the current evidence, we propose that adopting a stepped care approach, planning ahead, increasing support, motivational interviewing, and/or emotional regulation may serve as useful tools for parents when implementing extinction-based methods. By considering these techniques, more families may receive the benefits of improved infant sleep.
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Affiliation(s)
- Hannah Whittall
- Flinders University, College of Education, Psychology and Social Work, Adelaide, South Australia, Australia.
| | - Michal Kahn
- Flinders University, College of Education, Psychology and Social Work, Adelaide, South Australia, Australia
| | - Meg Pillion
- Flinders University, College of Education, Psychology and Social Work, Adelaide, South Australia, Australia
| | - Michael Gradisar
- Flinders University, College of Education, Psychology and Social Work, Adelaide, South Australia, Australia
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25
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Williamson AA, Gould R, Leichman ES, Walters RM, Mindell JA. Socioeconomic disadvantage and sleep in early childhood: Real-world data from a mobile health application. Sleep Health 2021; 7:143-152. [PMID: 33678602 DOI: 10.1016/j.sleh.2021.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 01/05/2021] [Accepted: 01/12/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Ariel A Williamson
- Sleep Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Russell Gould
- Johnson & Johnson Consumer Health, Skillman, New Jersey, USA
| | - Erin S Leichman
- Department of Psychology, Saint Joseph's University, Philadelphia, Pennsylvania, USA
| | | | - Jodi A Mindell
- Sleep Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Psychology, Saint Joseph's University, Philadelphia, Pennsylvania, USA
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26
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Williamson AA, Milaniak I, Watson B, Cicalese O, Fiks AG, Power TJ, Barg FK, Beidas RS, Mindell JA, Rendle KA. Early Childhood Sleep Intervention in Urban Primary Care: Caregiver and Clinician Perspectives. J Pediatr Psychol 2021; 45:933-945. [PMID: 32430496 DOI: 10.1093/jpepsy/jsaa024] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/14/2020] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite significant income-related disparities in pediatric sleep, few early childhood sleep interventions have been tailored for or tested with families of lower socio-economic status (SES). This qualitative study assessed caregiver and clinician perspectives to inform adaptation and implementation of evidence-based behavioral sleep interventions in urban primary care with families who are predominantly of lower SES. METHODS Semi-structured interviews were conducted with (a) 23 caregivers (96% mothers; 83% Black; 65% ≤125% U.S. poverty level) of toddlers and preschoolers with insomnia or insufficient sleep and (b) 22 urban primary care clinicians (physicians, nurse practitioners, social workers, and psychologists; 87% female; 73% White). Guided by the Consolidated Framework for Implementation Research, the interview guide assessed multilevel factors across five domains related to intervention implementation. Qualitative data were analyzed using an integrated approach to identify thematic patterns across participants and domains. RESULTS Patterns of convergence and divergence in stakeholder perspectives emerged across themes. Participants agreed upon the importance of child sleep and intervention barriers (family work schedules; household and neighborhood factors). Perspectives aligned on intervention (flexibility; collaborative and empowering care) and implementation (caregiver-to-caregiver support and use of technology) facilitators. Clinicians identified many family barriers to treatment engagement, but caregivers perceived few barriers. Clinicians also raised healthcare setting factors that could support (integrated care) or hinder (space and resources) implementation. CONCLUSIONS Findings point to adaptations to evidence-based early childhood sleep intervention that may be necessary for effective implementation in urban primary care. Such adaptations could potentially reduce significant pediatric sleep-related health disparities.
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Affiliation(s)
- Ariel A Williamson
- Children's Hospital of Philadelphia.,Perelman School of Medicine, University of Pennsylvania
| | - Izabela Milaniak
- Department of Psychology, University of Pennsylvania.,Nemours/Alfred I. duPont Hospital for Children
| | - Bethany Watson
- Department of Psychology, University of Pennsylvania.,Bellevue/New York University
| | | | - Alexander G Fiks
- Children's Hospital of Philadelphia.,Perelman School of Medicine, University of Pennsylvania
| | - Thomas J Power
- Children's Hospital of Philadelphia.,Perelman School of Medicine, University of Pennsylvania
| | | | - Rinad S Beidas
- Perelman School of Medicine, University of Pennsylvania.,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania
| | - Jodi A Mindell
- Children's Hospital of Philadelphia.,Department of Psychology, Saint Joseph's University
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27
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Daniel LC, Childress JL, Flannery JL, Weaver-Rogers S, Garcia WI, Bonilla-Santiago G, Williamson AA. Identifying Modifiable Factors Linking Parenting and Sleep in Racial/Ethnic Minority Children. J Pediatr Psychol 2021; 45:867-876. [PMID: 32447371 DOI: 10.1093/jpepsy/jsaa034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 04/16/2020] [Accepted: 04/20/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Young children from racial and ethnic minority backgrounds are at risk for poor sleep, yet few studies have tested behavioral interventions in diverse samples. This study tests factors that could contribute to associations between parenting skills and child sleep to inform interventions for children at risk of poor sleep outcomes. Specifically, we examined household chaos, caregiver sleep knowledge, and caregiver sleep quality as putative mediators that may be relevant to interventions seeking to improve child sleep. METHODS Caregivers (M age 31.83 years; 46.2% African American; 52.1% Hispanic/Latinx, 95% female) of 119 1- to 5-year-old children (M age 3.99 years; 43.7% African American; 42.0% Hispanic/Latinx, 14.3% biracial; 51.3% female) completed measures of parenting practices, child and caregiver sleep, household chaos, and sleep knowledge. Indices of pediatric insomnia symptoms (difficulty falling/remaining asleep) and sleep health (sleep duration/hygiene) were constructed based on previous research. Parallel mediation models were conducted using ordinary least squares path analysis. RESULTS Lower household chaos significantly attenuated the relationship between positive parenting skills and better child sleep health, suggesting chaos may serve as a potential mediator. There were no significant contributing factors in the pediatric insomnia model. Sleep knowledge was related to sleep health and caregiver sleep quality was related to pediatric insomnia, independent of parenting skills. CONCLUSION Interventions to improve sleep in early childhood may be enhanced by targeting parenting skills and household routines to reduce chaos. Future longitudinal research is needed to test household chaos and other potential mediators of child sleep outcomes over time.
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Affiliation(s)
| | | | | | | | - Wanda I Garcia
- Early Learning Research Academy, Rutgers University - Camden.,Community Leadership Center, Rutgers University - Camden
| | - Gloria Bonilla-Santiago
- Early Learning Research Academy, Rutgers University - Camden.,Community Leadership Center, Rutgers University - Camden
| | - Ariel A Williamson
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia.,Department of Psychiatry, University of Pennsylvania Perelman School of Medicine
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28
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Meltzer LJ, Wainer A, Engstrom E, Pepa L, Mindell JA. Seeing the Whole Elephant: a scoping review of behavioral treatments for pediatric insomnia. Sleep Med Rev 2020; 56:101410. [PMID: 33387973 DOI: 10.1016/j.smrv.2020.101410] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 01/07/2023]
Abstract
Pediatric insomnia is common, impacting up to a third of typically-developing, healthy children, and over 80% of children with neurodevelopmental disorders or chronic medical conditions. Previous reviews of behavioral interventions for pediatric insomnia have had a limited focus on a single age group, a specific population, and/or only randomized controlled trials. Furthermore, few reviews have considered non-sleep outcomes of both children and their parents. This scoping review provides a broader context, including studies regardless of research design or population, along with sleep and non-sleep study outcomes. Clear gaps in the literature were identified, highlighting the need for additional research in different populations, including school-age children and adolescents, racial/ethnic groups around the world, as well as youth with medical or psychiatric disorders. In addition, more research is needed on different features of treatment, including the delivery mode, involvement of all family members, non-sleep outcomes, and long-term follow-up.
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Affiliation(s)
- Lisa J Meltzer
- National Jewish Health, 1400 Jackson Street, G311, Denver, CO 80206, USA.
| | - Allison Wainer
- University of Colorado Anschutz Medical Campus, 12631 E. 17th Ave, Box F496, Aurora, CO 80045, USA
| | - Erin Engstrom
- University of Colorado Anschutz Medical Campus, 12631 E. 17th Ave, Box F496, Aurora, CO 80045, USA
| | - Lauren Pepa
- University of Colorado Anschutz Medical Campus, 12631 E. 17th Ave, Box F496, Aurora, CO 80045, USA
| | - Jodi A Mindell
- Saint Joseph's University, 5600 City Ave, Philadelphia, PA 19131, USA; Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
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29
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Ordway MR, Sadler LS, Jeon S, O'Connell M, Banasiak N, Fenick AM, Crowley AA, Canapari C, Redeker NS. Sleep health in young children living with socioeconomic adversity. Res Nurs Health 2020; 43:329-340. [PMID: 32306413 DOI: 10.1002/nur.22023] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/22/2020] [Accepted: 03/29/2020] [Indexed: 12/19/2022]
Abstract
Racially and ethnically diverse young children who live with socioeconomic adversity are at high risk for sleep deficiency, but few behavioral sleep interventions (BSIs) are tailored to their needs. To support the future development of a feasible, acceptable, and culturally relevant sleep intervention, we conducted a community-engaged, mixed-methods study with 40 low-income, racially, and ethnically diverse parents to describe sleep characteristics, sleep habits, and parental sleep knowledge of their 6-36-month-old children and to examine the associations between children's sleep characteristics and sleep habits. This report presents quantitative data from this mixed-methods study. We measured objective (actigraphy) and parent-reported sleep (Brief Infant Sleep Questionnaire) characteristics, sleep habits at bedtime, sleep onset, and during night awakenings, parental sleep knowledge, psychological function (Brief Symptom Inventory), and parenting stress (Parenting Stress Index). Children had low sleep duration (537.2 ± 54.7 nighttime and 111.2 ± 29.8 nap minutes), late bedtimes (22:36 ± 1.5 hr), and high bedtime variability (mean squared successive difference = 3.68 ± 4.31 hr) based on actigraphy. Parental knowledge about sleep recommendations was limited. Sleep habits before bedtime, at sleep onset, and during night awakenings were varied. Sixty-five percent of parents reported co-sleeping. Feeding near bedtime or during the night was associated with later bedtimes, more fragmented sleep, and increased bedtime variability. These findings suggest the need for BSIs to support earlier bedtimes and improve sleep duration and continuity by addressing modifiable behaviors. Tailored BSIs that consider socioecological influences on the development of sleep habits are needed.
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Affiliation(s)
| | - Lois S Sadler
- Yale Child Study Center, Yale University School of Nursing, West Haven, Connecticut
| | | | | | | | - Ada M Fenick
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | | | - Craig Canapari
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
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