Associations Between Disruptive Behavior Problems, Parenting Factors, and Sleep Problems Among Young Children

The time sensitive and dose-responsive association between parental corporal punishment and sleep disturbances in preschoolers: A prospective cohort study

BACKGROUND

To examine whether parental corporal punishment is associated with increased risk of concurrent and later sleep disturbances among preschoolers, and whether the association is time-sensitive or dose-responsive.

METHODS

This 3-year prospective cohort study used data from the Shanghai Children's Health, Education and Lifestyle Evaluation, Preschool(SCHEDULE-P). Participants were newly enrolled preschoolers in November 2016(wave 1) and followed up in April 2018(wave 2) and April 2019(wave 3). Parents reported the children's corporal punishment experiences and sleep disturbances at each wave survey. Children's risk of sleep disturbances in relation to corporal punishment was examined using logistic regression, adjusting for children's age, gender, emotional/behavioral problems, family annual income, and maternal educational level.

RESULTS

The participants of 19,668 children included 9436(47.98 %) females, with a mean age of 3.73(SD = 0.29) years at wave 1. Exposure to corporal punishment was associated with increased odds of concurrent sleep disturbances at wave 1, 2, and 3 (aOR,1.57; 95 % CI, 1.40-1.75; P < .001; aOR,1.60; 95 % CI, 1.43-1.80; P < .001; aOR,1.74; 95 % CI, 1.54-1.95; P < .001), respectively. Exposure to corporal punishment at any wave of preschool was associated with increased odds of sleep disturbances at wave 3, and the risks were greater for proximal and accumulative corporal punishment exposure.

CONCLUSION

There is a time-sensitive and dose-responsive association between corporal punishment and sleep disturbance among preschoolers, with greater risk of sleep disturbances for proximal and accumulative exposure of corporal punishment. Promoting positive parenting strategies and avoiding corporal punishment can be a promising strategy to prevent and intervene sleep disturbances in preschoolers.

The Associations Between Sleep and Externalizing and Internalizing Problems in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: Empirical Findings, Clinical Implications, and Future Research Directions

Sleep problems are common in youth with attention-deficit/hyperactivity disorder (ADHD). Externalizing and internalizing problems contribute to dysfunction in youth with ADHD and are amplified by disrupted sleep. This objective of this article is to synthesize empirical studies that examined the associations between sleep and internalizing or externalizing problems in individuals with ADHD. The main findings are that sleep problems precede, predict, and significantly contribute to the manifestation of internalizing and externalizing behavior problems among children and adolescents with ADHD. Clinicians should assess sleep and integrate sleep interventions into the management of youth with ADHD.

Understanding the Impact of Insufficient Sleep in Children with Behavior Problems on Caregiver Stress: Results from a U.S. National Study

Research indicates strong connections between child ADHD, child ODD/CD, and sleep. Children experiencing these concerns also have caregivers who report feeling more stress. However, no studies have examined how child ADHD and ODD/CD interact together and with insufficient sleep to potentially exacerbate caregiver stress. Data were acquired from the 2018/2019 National Survey of Children's Health, a nationally representative survey of parents or caregivers conducted across the United States (U.S.). The current study used data for children 6-17 years old with a final analytic sample size of 41,541, representing a total of 47,357,862 U.S. youth. Overall child ADHD and ODD/CD were each uniquely associated with increased caregiver stress, while adequate child sleep duration was related to decreased caregiver stress. However, these findings were qualified by a significant two-way interaction that revealed that caregiver stress among children with comorbid ADHD and ODD/CD was not significantly greater than that of children with ODD/CD alone. Significant interactions between sleep and ODD/CD on caregiver stress were generally not observed, except potentially in females with ADHD. Our findings underscore the importance of considering strategies to reduce both youth symptoms and caregiver stress simultaneously. Additionally, ensuring adequate sleep for all children is recommended.

Parasympathetic functioning and sleep problems in children with autism spectrum disorder

Respiratory sinus arrhythmia (RSA), an index of parasympathetic nervous system activity, has been linked with sleep quality among children with neurotypical development. The current study extended examination of these processes to children with autism spectrum disorder (ASD), a group at considerable risk for sleep problems. Participants included 54 children with ASD (aged 6-10 years, 43% Hispanic). RSA data were collected via a wired MindWare system during a 3-min baseline and a 3-min challenge task. Parents reported on their children's sleep problems and sleep duration using the Children's Sleep Habits Questionnaire, Abbreviated. Although no significant correlations emerged between RSA indices and parent-reported child sleep, baseline RSA and RSA reactivity interacted in the prediction of sleep problems. For children with higher RSA reactivity, higher baseline RSA was associated with fewer sleep problems, but for children with lower RSA reactivity, baseline RSA was not predictive. No main effects or interactions of RSA predicted sleep duration. Findings suggest resilience against sleep problems for children with ASD presenting with higher baseline RSA and higher RSA reactivity. Implications of these results center upon directly targeting psychophysiology (i.e., parasympathetic nervous system regulation) as a possible mechanism to improve sleep in children with ASD, and developing personalized interventions based on physiological markers of risk and resilience.

Electrodermal Activity Moderates Sleep-Behavior Associations in Children with Autism Spectrum Disorder

Relative to children without autism spectrum disorder (ASD), children with ASD experience elevated sleep problems that can contribute to behavioral comorbidities. This study explored the interaction between psychophysiology and sleep to determine which children with ASD may be at risk for, or resilient to, effects of poor sleep on daytime behavior. Participants included 48 children (aged 6-10 years) with ASD. Measures of sympathetic nervous system activity (electrodermal activity; EDA) were collected during a baseline and in response to a laboratory challenge task. Parents reported on their children's sleep problems and behavioral functioning, including broad externalizing symptoms and situational noncompliance, using standardized questionnaires and a clinical interview. EDA moderated the significant positive associations between sleep problems and both behavioral outcomes. The link between sleep problems and broad externalizing symptoms and situational noncompliance was positive and significant in the context of lower baseline EDA and nonsignificant in the context of higher baseline EDA. Sleep problems also interacted with EDA reactivity in predicting situational noncompliance, but not broad externalizing symptoms. Findings highlight the complex interplay among sleep, daytime behavior, and psychophysiology in children with ASD. Results are interpreted in the context of differential susceptibility and dual-risk frameworks. This study underscores the importance of high-quality sleep for children with ASD, especially those with the biological sensitivity or vulnerability factors (i.e., EDA) identified in this study. Clinical implications are discussed, and directions for future research are provided.

A primer on sleep for MFTs: Implications and practical considerations

Despite many marriage and family therapists (MFTs) utilizing the Biopsychosocial-Spiritual (BPSS) framework in assessment and treatment, there is still a lack of education on sleep and the implications for mental, emotional, and relational health. Newer research within many fields highlights the far-reaching spillover effects of short or poor-quality sleep that can affect our clients. MFTs need to know how to assess, how to provide proper psychoeducation, how to apply this knowledge in clinical settings, and how to collaborate with other healthcare providers. As such, the purpose of this article is threefold: (a) review the biopsychosocial-spiritual importance of sleep; (b) equip MFTs with information on sleep assessment, how to identify situations for referral, and how to provide psychoeducation on sleep hygiene; and (c) review important considerations for research and practice for MFTs.

The role of parenting stress in anxiety and sleep outcomes in toddlers with congenital heart disease

OBJECTIVES

This retrospective cohort study investigates how parenting stress, measured at 4 months of age by use of a classic three-dimensional parent-reported scale (Parenting Stress Index, 4th Ed. or PSI-4), can predict anxiety symptoms and quality of sleep at 24 months in toddlers with congenital heart disease (CHD).

STUDY DESIGN

Sixty-six toddlers with CHD followed at our cardiac neurodevelopmental follow-up clinic were included in this study. As part of their systematic developmental assessment program, parents completed questionnaires on their stress level (PSI-4) when their child was 4 months old, and on their child's anxiety symptoms and quality of sleep at 24 months. Eight multiple linear regression models were built on the two measures collected at 24 months using the PSI-4 scores collected at 4 months. For each measure, four models were built from the PSI-4 total score and its three subscales (Parental Distress, Parent-Child Dysfunctional Interaction, Difficult Child), controlling for sex and socioeconomic status.

RESULTS

The PSI-4 Difficult Child subscale, which focuses on parenting anxiety related to the child's behavioral problems and poor psychosocial adjustment, accounted for 17% of the child's anxiety symptoms at 24 months. The two other PSI-4 subscales (Parental Distress and Parent-Child Dysfunctional Interaction) and the PSI-4 total score did not contribute significantly to the models. None of the four regression models on perceived quality of sleep were significant. It is important to note that 33% of parents responded defensively to the PSI-4.

CONCLUSIONS

Parenting stress related to the child's behavioral problems and poor psychosocial adjustment, measured when the child is 4 months old, is associated with the child's ulterior anxiety symptoms. As very few standardized tools are available to assess the behavioral and psychoaffective development of infants, this study highlights the importance of early psychosocial screening in parents of infants with CHD. The high rate of significant Defensive Responding Indices reminds us to not take parent reports at face value, as their actual stress levels might be higher.

Sleep as a Moderator of Young Children's Traumatic Stress and Behavior Problems: a Treatment-Referred Sample

Empirical evidence suggests young children who have experienced trauma are at risk of developing sleep problems and behavior difficulties, but it is unclear of the specific relation between these behavioral health concerns. The primary purpose of the study is to determine whether sleep problems moderate the relation between traumatic stress and behavior problems in a sample of young children referred for treatment. A secondary purpose is to explore if sleep problems also moderate the relation between specific domains of traumatic stress (i.e., intrusion, avoidance, arousal) and behavior problems. Data from 170 preschoolers ages 3 through 5 referred for treatment were gathered at intake and utilized in this study. Results indicate sleep problems moderate the effect of overall traumatic stress on behavior problems. This statistical finding also was found with intrusive symptoms, and the moderation analyses approached significance with avoidance and arousal. Our findings highlight the importance for clinicians to assess for sleep problems when young children who have experienced trauma are referred to them for treatment, particularly if a low level of overall traumatic stress is present.

Parenting Practices, Bedtime Routines, and Consistency: Associations with Pediatric Sleep Problems

OBJECTIVES

Investigate the direct and moderating effects of daytime parenting practices on the relationship between bedtime routines and pediatric sleep problems.

METHODS

A community sample of 407 parents with children 2-10 years old completed measures of parenting practices (i.e., laxness and over-reactivity) and bedtime routines (i.e., consistency and reactivity to changes in routines). Sleep problems (i.e., severity and signaled night waking) were assessed by a parent-report questionnaire and sleep diaries.

RESULTS

Higher parenting laxness (β = .13) and less bedtime routine consistency (β = -.34) significantly predicted sleep problem severity. Laxness moderated the relationship between bedtime reactivity and sleep problem severity: when bedtime reactivity was high, higher parental laxness was associated with more severe sleep problems.

CONCLUSIONS

Daytime parenting practices are important to consider when children are reactive to changes in bedtime routines, as permissive or inconsistent daytime parenting practices were found to be associated with more severe sleep problems. Future research should examine the effects of parenting practices and bedtime routines on problematic signaled night waking in a clinical sample of children.

Longitudinal bidirectional association between sleep and behavior problems at age 6 and 11 years

BACKGROUND

Although a growing number of longitudinal studies have found that sleep problems precede behavior problems, few have examined potential bidirectional relationships longitudinally. The present study examined prospective associations between sleep problems and internalizing, externalizing, and attention problems over the course of childhood.

METHODS

Participants included 775 children from the China Jintan Cohort Study. Sleep problems were rated by mothers at ages six and 11.5, as well as self-reported by children at age 11.5. Behavior problems were rated by mothers and teachers at ages six and 11.5, and self-reported by children at age 11.5.

RESULTS

At age six, 15.0% of children were reported to have sleep problems as rated by mothers. At age 11, this prevalence was 12% as rated by mothers and 20% as rated by youth. Bidirectional relationships between sleep problems and behavior problems were observed. Mother-reported sleep problems at age six were predictive of self-reported internalizing and attention problems at age 11.5, even after controlling for baseline behavioral problems. At age six, teacher-reported externalizing, internalizing, and attention problems, and mother-rated internalizing and externalizing problems were all related to sleep problems at age 11.5, even after controlling for baseline sleep problems. Other sociodemographic covariates including child sex, age, and parental education were controlled for.

CONCLUSIONS

Findings provide further support for the reciprocal relationship between sleep problems and behavior problems. Early interventions that target both types of problems may be especially effective in preventing this aggravating health-behavior cycle.

The association of sleep quality and aggression: A systematic review and meta-analysis of observational studies

Poor sleep quality is closely related to aggression, but despite the promise of new therapeutic possibilities, a systematic synthesis of observational research on the association between sleep quality and aggression is lacking. This systematic review and meta-analysis examined the association between sleep quality and aggression, using the academic databases PubMed and PsycINFO. Subjective and objective measures of sleep quality were included, as well as multiple measures of aggression, assessing aggressive and externalizing behavior, anger, hostility and irritability. Ninety-two observational articles, containing 96 studies, encompassing a total of 58.154 children, adolescents and adults were sourced out of 7161 references identified. Methodological quality was moderate or strong in 76% of studies. Data for meta-analysis was available from 74 studies. Poorer sleep quality was associated with higher aggression in 80.8% of studies. Pooled results showed a correlation of 0.28 (95%CI 0.25-0.31; I² = 90.1%) and odds ratio of 3.61 (95%CI 1.13-11.51; I² = 88.3%). Effect estimates and heterogeneity varied according to population type and measurement instruments, but not according to article quality or age group. Our findings confirm that poor sleep quality is consistently associated with higher aggression. As most evidence is cross-sectional, more prospective and high-quality experimental evidence is required to elucidate cause-effect and optimize prevention and treatment of aggression.

Grandparental care and sleep disturbances in preschool children: a population-based prospective cohort study

OBJECTIVES

Sleep disturbances are common in preschoolers, and profoundly affected by parenting. Grandparents are increasingly involved in childcare and have attracted worldwide attention for their potential impacts on child well-being. However, no studies have explored child sleep health within the context of grandparental care. We aimed to explore the association between grandparents as primary caregivers and children's sleep disturbances.

METHODS

Participants included 20,324 preschoolers from the Shanghai Children's Health, Education and Lifestyle Evaluation-Preschool (SCHEDULE-P) in Shanghai, China. They were initially assessed in November 2016 and were reassessed in April 2018 and April 2019. Children's primary caregivers were collected at each survey. Sleep disturbances were assessed by the Children's Sleep Habits Questionnaire (CSHQ).

RESULTS

At baseline, 84.4% of children had global sleep disturbances (CSHQ total score >41). Compared with parents, random-effects model indicated that grandparents as primary caregivers increased the adjusted odds ratio (OR) for children's global sleep disturbances by 30% (OR [95%CI]: 1.30 [1.21, 1.40]). To the specific domains of CSHQ, two-way repeated-measures ANOVA showed significant "caregiver transition" group × wave interaction in the behavioral sleep disturbances, such as "Bedtime Resistance" (p < 0.001). At each survey, children with grandparents as primary caregivers demonstrated significant higher behavioral sleep disturbances than their counterparts with parental care.

CONCLUSIONS

Grandparental care is associated with increased sleep disturbances, particularly behavioral sleep disturbances, in preschoolers. Future studies should explore the underlying mechanisms and whether sleep programs targeting grandparents can decrease children's sleep disturbances.

The Associations Between Sleep and Externalizing and Internalizing Problems in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: Empirical Findings, Clinical Implications, and Future Research Directions

Sleep problems are common in youth with attention-deficit/hyperactivity disorder (ADHD). Externalizing and internalizing problems contribute to dysfunction in youth with ADHD and are amplified by disrupted sleep. This objective of this article is to synthesize empirical studies that examined the associations between sleep and internalizing or externalizing problems in individuals with ADHD. The main findings are that sleep problems precede, predict, and significantly contribute to the manifestation of internalizing and externalizing behavior problems among children and adolescents with ADHD. Clinicians should assess sleep and integrate sleep interventions into the management of youth with ADHD.

Early parental positive personality and stress: Longitudinal associations with children's sleep

OBJECTIVES

The current study examined the influence of early parental stress and positive parent personality during infancy on sleep in middle childhood. Further, the role of positive parent personality as a buffer of the association between parental stress and sleep was considered.

METHODS

Participants included 381 twins and their primary caregivers who were recruited from birth records in the United States. Primary caregivers completed survey assessments via phone when twins were 12 and 30 months of age to assess multiple dimensions of parental stress and positive parent personality. Approximately 6 years later (M = 5.78, SD = 0.42), twins participated in an intensive assessment that included wearing actigraph watches to provide an objective measurement of sleep, while primary caregivers completed daily diaries regarding twins' sleep.

RESULTS

Positive parent personality was associated prospectively with longer actigraphy sleep duration and higher parent-reported sleep quality/daytime functioning. Parental stress was associated prospectively with greater variability in sleep duration. Positive parent personality moderated the parental stress - sleep-timing relation, such that greater parental stress was associated with a later midpoint of the sleep period only for children with parents low on positive personality (e.g., low optimism). All other findings were non-significant.

CONCLUSIONS

Findings suggest that both positive attributes and stress may influence sleep in middle childhood and that low parent positive personality may exacerbate associations between parental stress and later timing of sleep periods in children. Early interventions to promote healthy sleeping may consider focusing on decreasing parental stress and increasing parental empathy and optimism as early as infancy. Statement of contribution What is already known on this subject? Early-life experiences, especially adversity, have been related to health outcomes among adults and children, such that negative experiences are associated with poor health outcomes. Poor sleep (e.g., short duration, poor quality) among children is associated with negative outcomes including poorer cognitive performance and higher adiposity. What does this study add? This study used a prospective design to understand relations between early parent-related factors and child sleep. Early parental stress and positive parent personality were associated with objective sleep quality. Positive parent personality during infancy may have promotive/protective influences on sleep later in childhood.