Adverse associations of sleep problems in Australian preschoolers: national population study

Feasibility of an Unguided, Parent-Focused, Online Program for Sleep Problems in Young Children: The Lights Out Online Program

Sleep problems in young children are highly prevalent and place children at risk for numerous detrimental child and family outcomes. This pilot study aimed to assess the feasibility of an unguided, parent-focused, online sleep intervention, the Lights Out Online program, in terms of adherence rates, acceptability to parents, and effects on (a) child sleep, anxiety, and behaviour problems, and (b) parental self-efficacy, and parent sleep, depression, anxiety. The study was a pilot, open (uncontrolled) trial with a within-group repeated measures (baseline (T1), 12-weeks post-baseline (T2)) design. Participants were 24 parents (Mage = 36.2, SD = 4.1) of children aged 3-6 years (Mage = 4.1 years, SD = 1.1) with sleep problems. Participants completed an average of 3.58 out of 4 sessions by T2, and parents reported satisfaction with program content and presentation. A series of mixed-effects linear regression models demonstrated significant improvements in child sleep, child anxiety, child behaviour problems, parent sleep, parent anxiety and parental self-efficacy, from T1 to T2. However, significant improvements were not demonstrated for parent depression and parent stress. The results of this study should be taken with caution given the small sample size and lack of control group. However, the study provides preliminary support for the feasibility of Lights Out Online.

Topical review: sleep regulation as a novel target for treating preschool-aged children with attention-deficit/hyperactivity disorder symptoms

OBJECTIVE

Elevated attention-deficit/hyperactivity disorder (ADHD) symptoms in preschoolers are a risk factor for poorer psychiatric health, cognitive deficits, and social and academic impairment across the lifespan. The first-line treatment for these preschoolers, behavioral parent training (BPT), reduces children's disruptive behaviors and parenting stress, yet its impact on core ADHD symptoms is inconsistent. Early interventions targeting biological mechanisms linked to core ADHD pathophysiology are critically needed.

METHODS

This topical review explores sleep dysregulation as a potential key target for early intervention for ADHD symptoms among preschoolers.

RESULTS

Sleep dysregulation is common in school-aged children with ADHD, and treating sleep improves core ADHD symptoms in older children. Cross-sectional and prospective research with preschoolers offers compelling evidence that sleep dysregulation and ADHD symptoms are closely linked over the course of early development. BPT and behavioral sleep medicine (BSM) interventions share an underlying theoretical framework and could be streamlined to target sleep in addition to daytime behaviors.

CONCLUSIONS

Novel early interventions targeting underlying biological mechanisms linked to core ADHD pathophysiology are critically needed to improve the trajectories of ADHD symptoms, comorbidity, and functional deficits for preschoolers with elevated ADHD symptoms. Sleep regulation is a promising mechanistic treatment target for this population, and future interventions may draw from the shared behavioral principles of BPT and BSM to target behaviors across the 24-hr period and employ scalable formats to optimize the number of families who can benefit from parent-based interventions targeting ADHD symptoms and sleep in early development.

Sleep quality in children with hepatic glycogen storage diseases, a prospective observational pilot study

Background

Hepatic glycogen storage diseases (GSDs) are characterised by enzyme defects affecting liver glycogen metabolism, where carbohydrate supplementation to prevent overnight hypoglycaemia is common. Concerns around sleep quality in hepatic GSDs relate to emerging evidence that overnight dysglycaemia impacts sleep quality.

Methods

This prospective observational study reported sleep quality and duration in children with hepatic GSDs over 7 days utilising: actigraphy (Actiwatch 2 by Phillips Respironics), sleep diaries, proxy reported age-appropriate sleep and quality-of-life (QoL) questionnaires, in the context of nocturnal glycaemic profiles continuous glucose monitor (CGM, Dexcom G6) and nocturnal dietary management strategies. Significant hypo- and hyperglycaemia were defined as ≥1% of sleep diary documented nocturnal period, recording <3.5 and >10.0 mmol/L, respectively.

Results

Seven children with hepatic GSD (aged 1-17 years) participated. Objective sleep quality was poor, with actigraphy demonstrating that no child achieved the minimum sleep duration recommended for age. Subjective sleep quality was also poor, with 4/5 documenting significant daytime sleepiness and 6/6 reporting poor sleep hygiene. Children prescribed overnight bolus feeds (OBF) (n = 2) recorded shorter sleep duration compared to other nocturnal management strategies. Parent-reported QoL suggested poor disease-related QoL outcomes for this cohort.

Conclusion

Objective and subjective sleep disturbances and reduced QoL are common within our sample of children with hepatic GSD. From our observations these outcomes may be linked to nutritional overnight interventions, especially OBFs, rather than overnight glucose levels. Consideration of the impacts of overnight feeding strategies on sleep quality and QoL in children with hepatic GSD should inform future management strategies.

Toddler Screen Use Before Bed and Its Effect on Sleep and Attention: A Randomized Clinical Trial

Importance

Toddler screen time has been associated with poorer sleep and differences in attention. Understanding the causal impact of screen time on early development is of the highest importance.

Objective

To test (1) the feasibility of the 7-week parent-administered screen time intervention (PASTI) in toddlers (aged 16-30 months) who have screen time in the hour before bed and (2) the impact of PASTI on toddlers' sleep and attention.

Design, Setting, and Participants

This assessor-blinded, UK-based randomized clinical trial was conducted between July 2022 and July 2023. This was a single-site study that enrolled families with a toddler aged between 16 and 30 months, living within 75 miles of the Babylab, and with 10 minutes or more of screen time in the hour before bed on 3 or more days a week. Exclusion criteria were (1) a genetic or neurological condition, (2) premature birth (<37 weeks), and (3) current participation in another study.

Interventions

Families were randomized (1:1:1) to (1) PASTI: caregivers removed toddler screen time in the hour before bed and used activities from a bedtime box instead (eg, reading, puzzles); (2) bedtime box (BB only): used matched before-bed activities, with no mention of screen time; or (3) no intervention (NI): continued as usual.

Main Outcomes and Measures

Feasibility outcomes: participation rate, intervention adherence, retention, family experiences, and assessment acceptability. Efficacy outcomes: screen use, actigraphy-measured sleep, and eye-tracking attention measures.

Results

A total of 427 families were screened, 164 were eligible (38.4%), and 105 families were randomized (mean [SD] age, 23.7 [4.6] months; 60 male [57%]). The trial was feasible, with 99% participant (104 of 105) retention and 94% of families (33 of 35) adhering to PASTI. PASTI showed reductions in parent-reported screen time (vs NI: Cohen d = -0.96; 95% CI, -1.32 to -0.60; vs BB only: Cohen d = -0.65; 95% CI, -1.03 to -0.27). PASTI showed small to medium improvements in objectively measured sleep efficiency (vs NI: Cohen d = 0.27; 95% CI, -0.11 to 0.66; vs BB only: Cohen d = 0.56; 95% CI, 0.17-0.96), night awakenings (vs NI: Cohen d = -0.28; 95% CI, -0.67 to 0.12; vs BB only: Cohen d = -0.31; 95% CI, -0.71 to 0.10), and reduced daytime sleep (vs NI: Cohen d = -0.30; 95% CI, -0.74 to 0.13) but no difference compared with BB only. There was no observable effect of PASTI on objective measures of attention. Compared with BB only, PASTI showed a difference on parent-reported effortful control (Cohen d = -0.40; 95% CI, -0.75 to -0.05) and inhibitory control (Cohen d = -0.48; 95% CI, -0.77 to -0.19), due to an increase in BB-only scores.

Conclusions and Relevance

Results of this randomized clinical trial show that, supporting pediatric recommendations, removing screen time before toddler bedtime was feasible and showed modest preliminary beneficial effects on sleep. A future full confirmatory trial is needed before PASTI's adoption by parents and pediatricians.

Trial Registration

ISRCTN.org Identifier: ISRCTN58249751.

Regular sleep habits in toddlers are associated with social development and brain coherence

OBJECTIVE

Although sleep habits are associated with the development of toddlers, factors affecting social development and brain function remain unclear. We aimed to elucidate the relationship between sleep habits and social development as well as brain coherence in toddlers.

METHODS

We used the data set at 1.5-2 years old, in the longitudinal study until 6 years old. We evaluated sleep parameters, such as average wake-up time, bedtime, nighttime sleep duration, total sleep duration, and the standard deviation (SD) of sleep habits. We also examined the development, including the social stimuli fixation percentage using Gazefinder® and electroencephalography (EEG) coherence between brain regions.

RESULTS

Seventy-two children (37 boys and 35 girls) were included. The fixation percentage for the human face was negatively correlated with the SD of the total sleep duration, nighttime sleep duration, nap duration, and bedtime (r = -0.516, p = 0.000; r = -0.331, p = 0.005; r = -0.330, p = 0.005; and r = -0.324, p = 0.005, respectively). The EEG analysis indicated that α-band coherence in the right centro-parietal area was negatively correlated with the total sleep duration (r = -0.283, p = 0.016). The path diagram demonstrated a direct significant effect of sleep duration irregularity on development including social communication and fixation percentage for human faces. Additionally, total sleep duration exhibited a direct effect on α cortical coherence in the right centro-parietal area.

CONCLUSIONS

In this study, we found an association between sleep irregularity and the development of social communication, preference for humans, and brain coherence in toddlers. We suggest that regular sleep plays an important role in promoting the development of social communication.

Sleep Deficiency in Young Children

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.

Relationship between sleep disturbance and developmental status in preschool-aged children with developmental disorder

BACKGROUND

Sleep has been known to affect childhood development. Sleep disturbance is likely more common in children with developmental delay (DD) than in typical development. There are few studies on the correlation between sleep disturbance and developmental features in children with DD. Therefore, this study aimed to evaluate the associations between the two in children with DD.

METHODS

A total of 45 children (age range 27.0 ± 11.1) with DD were recruited and evaluated using the Sleep Disturbance Scale for Children (SDSC) and Bayley Scales of Infant and Toddler Development (BSID-III). The outcomes are expressed as means and standard deviations. The correlation between SDSC and BSID-III was assessed using Spearman's rank correlation test. Multiple regression analysis was performed to investigate the relationship between BSID-III domains and SDSC questionnaire subscales. Statistical significance was set at p < 0.05.

RESULTS

Based on the correlation analysis and subsequent hierarchical regression analysis, cognition and socio-emotional domains of BSID-III were significantly associated with the DOES subscale of the SDSC questionnaire. In addition, the expressive language domain of the BSID-III was found to be associated with the DA subscale of the SDSC questionnaire. It seems that excessive daytime sleepiness might negatively affect emotional and behavioral problems and cognitive function. Also, arousal disorders seem to be related to memory consolidation process, which is thought to affect language expression.

CONCLUSION

This study demonstrated that DA and DOES subscales of the SDSC questionnaire were correlated with developmental aspects in preschool-aged children with DD. Sleep problems in children with DD can negatively affect their development, thereby interfering with the effectiveness of rehabilitation. Identifying and properly managing the modifiable factors of sleep problems is also crucial as a part of comprehensive rehabilitation treatment. Therefore, we should pay more attention to sleep problems, even in preschool-aged children with DD.

Sleep patterns among preschool offspring of parents with and without psychopathology: Association with the development of psychopathology in childhood

BACKGROUND

Disturbed sleep during early childhood predicts social-emotional problems. However, it is not known how various early childhood sleep phenotypes are associated with the development of childhood psychopathology, nor whether these relationships vary as a function of parental psychopathology. We identified sleep phenotypes among preschool youth; examined whether these phenotypes were associated with child and parent factors; and determined if early sleep phenotypes predicted later childhood psychopathology.

METHODS

Using data from the Pittsburgh Bipolar Offspring study, parents with bipolar disorder (BD), non-BD psychopathology, and healthy controls reported about themselves and their offspring (n = 218) when their children were ages 2-5. Offspring and parents were interviewed directly approximately every 2 years from ages 6-18. Latent class analysis (LCA) identified latent sleep classes; we compared these classes on offspring demographics, parental sleep variables, and parental diagnoses. Kaplan-Meier survival models estimated hazard of developing any new-onset Axis-I disorders, as well as BD specifically, for each class.

RESULTS

The optimal LCA solution featured four sleep classes, which we characterized as (1) good sleep, (2) wake after sleep onset problems, (3) bedtime problems (e.g., trouble falling asleep, resists going to bed), and (4) poor sleep generally. Good sleepers tended to have significantly less parental psychopathology than the other three classes. Risk of developing new-onset Axis-I disorders was highest among the poor sleep class and lowest among the good sleep class.

CONCLUSIONS

Preschool sleep phenotypes are an important predictor of the development of psychopathology. Future work is needed to understand the biopsychosocial processes underlying these trajectories.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

Contextual considerations in infant sleep: Offering alternative interventions to families

Infant sleep problems are one of the commonly reported reasons parents seek professional help, yet what constitutes a "sleep problem" depends on the models used to explain the development of infant sleep. The current models are based on research conducted in the western context where infant solitary sleeping is the norm. Parent-child co-sleeping is the norm in many cultures around the world. We argue that the primary focus of current research on parent-child interactions as the mediating context for the development of infant sleep problems has inherently made these models and ensuing interventions less sensitive and applicable to infant sleep problems in the context of co-sleeping families. When families present for help with infant sleep difficulties, extinction based behavioral interventions or interventions focused on reducing parental presence at bedtime are commonly recommended. These recommendations may not always align with cultural values and parenting practices of all families, therefore precluding these families from getting necessary help. In attempting to provide families with choices that depart from behavioral based interventions, this paper draws on research and adapts current models to propose an alternative to conceptualize perceptions of infant sleep problems that may be sensitive to and applied across various cultural and personal contexts. We attempt to provide a rationale for interventions that are inclusive and sensitive to families where reduced parental nighttime responsiveness may not be a preferred choice.

The impact of sleep difficulties in children with attention deficit hyperactivity disorder on the family: a thematic analysis

STUDY OBJECTIVES

Attention deficit hyperactivity disorder is a complex but common neurodevelopmental condition characterized by symptoms of inattention, hyperactivity, and impulsivity associated with a significant level of academic, social, and functional impairment. Problems around sleep frequently co-occur with attention deficit hyperactivity disorder and are thought to affect 50% to 80% of children and adults with the condition. Sleep issues typically include trouble falling asleep, bedtime resistance, night-time waking, and early rising. The impact of these problems on families and parents is profound but poorly researched.

METHODS

Semistructured interviews took place with 12 mothers of children with attention deficit hyperactivity disorder who struggle with sleep. Participants were asked about sleeping patterns and issues, methods used to improve sleep, the impact on parents' sleep and wider family life, and involvement with clinical services and support groups. Data were analyzed using thematic analysis.

RESULTS

Three themes were identified in the data: a constant battleground; the cumulative effect of lack of sleep: impact on functioning and the wider family; a mixed bag of strategies: the tried, tested, and needed. Long-term sleep issues and challenging behavior at bedtime had substantial negative effects on families. Parents experiencing sleep deprivation experienced functional impairments to daily life and well-being and strain on relationships with children and spouses.

CONCLUSIONS

Findings revealed parents were consistently and profoundly impacted by their children's sleep problems. Parents sought strategies and support in many different ways but were often unsuccessful.

CITATION

French B, Quain E, Kilgariff J, Lockwood J, Daley D. The impact of sleep difficulties in children with attention deficit hyperactivity disorder on the family: a thematic analysis. J Clin Sleep Med. 2023;19(10):1735-1741.

Fetal SSRI antidepressant exposure and infant sleep: Findings from the MPEWS pregnancy cohort study

This longitudinal study examines the association between fetal Selective Serotonergic Reuptake Inhibitor antidepressant exposure and infant sleep behaviours at six and 12 months of age and focus on three of the most commonly prescribed antidepressants in pregnancy. This study utilises data on 698 women recruited at less than 20 weeks of pregnancy and are followed up at six and 12 months postpartum. Women were recruited into one of three groups: those taking either sertraline, citalopram or escitalopram antidepressants in pregnancy (n = 85); women with a depressive disorder who were not taking antidepressants (non-medicated depressed, NMD; n = 82); and, and a control group of women (n = 531). At six and 12 months, data were collected on breastfeeding and sleep location and infant sleep was measured using the Brief Infant Sleep Questionnaire. Antidepressants sertraline, escitalopram and citalopram were not associated with increased infant waking or time awake. However, sertraline was associated with longer time for an infant to go to sleep. This study provides reassurance that SSRI antidepressants and, in particular, sertraline, escitalopram and citalopram are not associated with infant sleep behaviours that are commonly regarded as problematic including night waking. Further replication of these findings, including with direct measures of infant sleep, are recommended.

Treating sleep problems in young children: A randomised controlled trial of a group-based, parent-focused behavioural sleep intervention

This study tested the efficacy of a 5 × 1.5 h/session, group-based, parent-focused, behavioural intervention (BI) targeting sleep problems in preschool children. Parents were randomised to either the BI (N = 62) or care as usual (CAU; N = 66) conditions. Outcomes included sleep, anxiety, behavioural problems, internalising and externalising symptoms, transition to school and academic achievement. Assessments were conducted at pre- and post-BI intervention (in the year prior to formal schooling), and then at follow-ups 1 and 2 in the first year of formal schooling. Relative to the CAU, the BI condition demonstrated significantly greater improvements in sleep, anxiety, behaviour problems and internalising and externalising symptoms from pre-to post-intervention. Improvements in sleep, anxiety, and internalising symptoms were maintained, while behaviour and externalising symptoms were further improved upon at school follow-up 2. For the BI group, improvements in sleep at post-intervention were found to mediate improvements in anxiety, internalising, and externalising symptoms, but not behaviour problems, at school follow-ups 1 and 2. There were no significant effects of condition on school transition or academic outcome measures. The results suggest that the BI is effective for sleep, anxiety, behaviour, internalising and externalising symptoms, but not for school transition or academic outcomes. ANZCTR NUMBER: ACTRN12618001161213.

Examining bidirectional associations between sleep and behavior among children with attention-deficit/hyperactivity disorder

Background

Children with attention-deficit/hyperactivity disorder (ADHD) have more sleep problems than their peers which contribute to behavioral and functional impairments. This study examines the bidirectional relationship between nightly sleep (i.e., total sleep time and sleep efficiency) and daily behavior of children with ADHD.

Method

Forty-three children (ages 6-13 [mean = 9.05, 54% male, 77% medicated]) participated in a 2-week study during an ADHD Summer Treatment Program (STP). Sleep was measured with actigraphy. Behavior was assessed using STP clinical data and daily parent and counselor ratings of ADHD symptoms, oppositional defiant disorder behaviors, and emotion regulation (e.g., difficulty regulating emotional disposition and controlling emotions). We hypothesized that healthier night's sleep measured by actigraphy (i.e., sleep efficiency and total sleep time [TST]) would relate to less ADHD symptoms, less emotional dysregulation, and better academic performance the next day. Additionally, we hypothesized that less ADHD symptoms, less emotional dysregulation, and greater academic performance would relate to healthier sleep that night.

Results

Higher nightly sleep efficiency was related to improved parent-ratings of ADHD the next day (R 2 = 0.04, p = 0.04) and improved parent-ratings of ADHD during the day lead to higher sleep efficiency that night (R 2 = 0.002, p = 0.02). Higher rates of daily assignment completion were related to higher sleep efficiency at night (R 2 = 0.035, p = 0.03). TST was not related to any behavioral outcomes.

Conclusion

Sleep efficiency may be more relevant than TST to behavioral performance the next day. Additionally, a bidirectional relationship exists between sleep efficiency and parent ratings of ADHD. Findings highlight the importance of assessing for manifestations of poor sleep efficiency, waking minutes, and wakings after sleep onset when diagnosing and treating ADHD.

The association between family function and sleep disturbances of preschool children in rural areas of China: a cross-sectional study

This study aimed to explore the association between family function and sleep disturbances in preschool children in rural areas of China. Caregivers of preschool children completed sociodemographic questionnaires, the Children's Sleep Habits Questionnaire (CSHQ), the Self-rating Anxiety Scale (SAS) and the Family APGAR scale. Using sleep disturbances in children as the dependent variable, family function and other related factors as independent variables, binary logistic regression analyses were performed to examine associations between family function and sleep disturbances in children. A total of 3,636 caregivers of preschool children were enrolled in our study, and the prevalence of sleep disturbances among their preschool children was 89.4%. In our study, lower family function was associated with higher risk of sleep disturbances among preschool children. After adjusting for age (years), education level of mother, discipline attitudes of father and mother, only child status and caregivers' anxiety, the associations were statistically significant both in families of which caregivers of children are their parents or other relatives. (AOR for parents = 1.487, 95% CI:1.152-1.919, P = 0.002; AOR for other relatives = 1.963, 95% CI:1.302-2.958, P = 0.001). Our study results indicated that family function was associated with sleep disturbances in preschool children, and future high-quality cohort studies are needed to explore this topic in more detail.

Association between attention-deficit/hyperactivity symptoms and sleep in preschoolers

INTRODUCTION

Sleep problems are frequent in children with attention-deficit/hyperactivity disorder (ADHD). Some authors have tried to characterize paediatric sleep habits in Portugal, but none has focused on preschool-age children nor attempted to establish their association with ADHD. We aimed to assess the prevalence of ADHD symptoms in preschool-age children and to study their association with sleep habits.

MATERIAL AND METHODS

We conducted a cross-sectional study. We distributed questionnaires to a random sample of caregivers of children enrolled in early childhood education centres in Porto. We collected data on sociodemographic characteristics, television watching and outdoor activities. We assessed ADHD symptoms and sleep habits with the Portuguese versions of the Conners' Parents Rating Scale, Revised and the Children's Sleep Habits Questionnaire (CSHQ-PT), respectively.

RESULTS

The study included 381 preschoolers (50.90% male). We found high scores for ADHD symptoms in 13.10%, with a higher prevalence in girls (14.40% vs. 11.85%; P = 0.276). In the CSHQ-PT, 45.70% of participants had a mean total score greater than 48, which is the cut-off point applied in the screening of sleep disturbances in the Portuguese population. There was a significant association between high scores for ADHD symptoms and a lower maternal education level (P < 0.001), a shorter sleep duration (P = 0.049), and higher scores on parasomnias (P = 0.019) and sleep disordered breathing (P = 0.002) in CSHQ-PT subscales.

CONCLUSIONS

ADHD and sleep disorders are common in preschoolers, in Porto, and this study suggests some clinical correlations between them. Since these interactions are complex and far from being elucidated, further studies are paramount to provide guidance for prevention and managing strategies in younger children at risk for ADHD.

The association between atopic dermatitis, cognitive function and school performance in children and young adults

BACKGROUND

Children with atopic dermatitis (AD) may have disturbed sleep, affected self-esteem and decreased quality of life, likely interfering with performance in school.

OBJECTIVES

To examine the association between hospital-managed paediatric AD, school performance and cognitive function.

METHODS

In this cross-sectional study we linked data from the Danish national registers and identified three populations between 2001 and 2019. Population 1 comprised children with graduation grades registered from lower secondary school, population 2 comprised adolescents with registration of an upper secondary graduation mean, and population 3 comprised male conscripts with registration of an IQ test score. AD was defined as a hospital diagnostic code (inpatient or outpatient) prior to the exam or conscription date, and was stratified according to severity, activity and atopic comorbidity. Outcomes included graduation mean from lower and upper secondary school, special educational assistance in primary and lower secondary school, and IQ at conscription.

RESULTS

In total, 770 611 (12 137 with AD), 394 193 (6261 with AD) and 366 182 (4539 with AD) children and adolescents were included in populations 1 (lower secondary graduation), 2 (upper secondary graduation) and 3 (conscription), respectively. In lower secondary school, children with severe AD had significantly lower overall, written and oral graduation grade means compared with children with mild AD: respectively, difference -0.29 [95% confidence interval (CI) -0.45 to -0.13, P < 0.001], difference -0.26 (95% CI -0.42 to -0.10, P = 0.0016) and difference -0.30 (95% CI -0.49 to -0.11, P = 0.0018). In upper secondary school, adolescents with AD performed similarly to their peers without AD. Young men with AD scored significantly lower IQ test means at conscription examination than male conscripts without AD: difference -0.60 (95% CI -0.87 to -0.32, P < 0.001).

CONCLUSIONS

AD, in particular when severe, is associated with lower school performance in childhood and IQ in young men, which can interfere with academic achievements in life. Optimization of treatment of children with AD and specific educational support to children with severe AD could be needed.

Longitudinal associations between parent, child, family factors and dyssomnias in children from birth to 8 years: The CIKEO study

BACKGROUND

Dyssomnias, are the most common parent-reported sleep complaints in young children. The present study investigated the prevalence, one-year development (incidence and persistence) of dyssomnia in early childhood, and the parent, child, and family factors associated with dyssomnia.

METHODS

Longitudinal data of 700 children aged 0-8, gathered in the CIKEO cohort study in the Netherlands were analyzed. Dyssomnias were defined as the presence of night awakenings ≥3 times per night or sleep-onset latency of >30 min. Least absolute shrinkage and selection operator (LASSO) was used to identify the parental, child, and family factors associated with the incidence and persistence of dyssomnias in children.

RESULTS

The mean age of the children (47 % girls) was 3.2 ± 1.9 years at baseline and 4.4 ± 1.8 years at follow-up. The prevalence of dyssomnias was 13.3 % and 15.4 % at baseline and follow-up, respectively. The incidence and persistence rates of dyssomnias at follow-up were 12.0 % and 37.6 %, respectively. New incidence of insomnia was associated with being a girl, having medical conditions, experiencing stressful life events, and lower parenting self-efficacy at baseline (P < 0.05). Higher levels of parental psychological distress were associated with the persistence of dyssomnias in children (P < 0.05).

CONCLUSIONS

Dyssomnias are common with a moderate persistent rate in young children. Several parental, child, and family factors in relation to the incidence and persistence of dyssomnias were identified. Preventive programs and interventions targeting modifiable factors, particularly parental psychological distress, parenting self-efficacy, and resilience to stressful life events, might benefit child sleep.

Development of the circadian system in early life: maternal and environmental factors

In humans, an adaptable internal biological system generates circadian rhythms that maintain synchronicity of behavior and physiology with the changing demands of the 24-h environment. Development of the circadian system begins in utero and continues throughout the first few years of life. Maturation of the clock can be measured through sleep/wake patterns and hormone secretion. Circadian rhythms, by definition, can persist in the absence of environmental input; however, their ability to adjust to external time cues is vital for adaptation and entrainment to the environment. The significance of these external factors that influence the emergence of a stable circadian clock in the first years of life remain poorly understood. Infants raised in our post-modern world face adverse external circadian signals, such as artificial light and mistimed hormonal cues via breast milk, which may increase interference with the physiological mechanisms that promote circadian synchronization. This review describes the very early developmental stages of the clock and common circadian misalignment scenarios that make the developing circadian system more susceptible to conflicting time cues and temporal disorder between the maternal, fetal, infant, and peripheral clocks.

Reflexive Evidence and Systems interventions to Prevention Obesity and Non-communicable Disease (RESPOND): protocol and baseline outcomes for a stepped-wedge cluster-randomised prevention trial

INTRODUCTION

Systems science methodologies have been used in attempts to address the complex and dynamic causes of childhood obesity with varied results. This paper presents a protocol for the Reflexive Evidence and Systems interventions to Prevention Obesity and Non-communicable Disease (RESPOND) trial. RESPOND represents a significant advance on previous approaches by identifying and operationalising a clear systems methodology and building skills and knowledge in the design and implementation of this approach among community stakeholders.

METHODS AND ANALYSIS

RESPOND is a 4-year cluster-randomised stepped-wedge trial in 10 local government areas in Victoria, Australia. The intervention comprises four stages: catalyse and set up, monitoring, community engagement and implementation. The trial will be evaluated for individuals, community settings and context, cost-effectiveness, and systems and implementation processes. Individual-level data including weight status, diet and activity behaviours will be collected every 2 years from school children in grades 2, 4 and 6 using an opt-out consent process. Community-level data will include knowledge and engagement, collaboration networks, economic costs and shifts in mental models aligned with systems training. Baseline prevalence data were collected between March and June 2019 among >3700 children from 91 primary schools.

ETHICS AND DISSEMINATION

Ethics approval: Deakin University Human Research Ethics Committee (HREC 2018-381) or Deakin University's Faculty of Health Ethics Advisory Committee (HEAG-H_2019-1; HEAG-H 37_2019; HEAG-H 173_2018; HEAG-H 12_2019); Victorian Government Department of Education and Training (2019_003943); Catholic Archdiocese of Melbourne (Catholic Education Melbourne, 2019-0872) and Diocese of Sandhurst (24 May 2019). The results of RESPOND, including primary and secondary outcomes, and emerging studies developed throughout the intervention, will be published in the academic literature, presented at national and international conferences, community newsletters, newspapers, infographics and relevant social media.

TRIAL REGISTRATION NUMBER

ACTRN12618001986268p.

Sleep Duration and Kindergarten Adjustment

OBJECTIVES

The current study examined longitudinal linkages between child sleep duration and children's socioemotional, learning engagement, executive functioning, and academic outcomes across the full kindergarten (K) year.

METHODS

A measurement-burst design was employed to examine 3 different measures of child sleep duration in 7-day bursts at pre-K (July-August), early K (late September), mid-K (late November), and late K (mid-to-late April), using wrist actigraphy. These measures included mean amounts of child sleep per 24-hour period across the full week, proportion of 24-hour periods per week that children slept 10 or more hours, and proportion of nighttime sleep periods per week that children slept 10 or more hours. Children's outcomes at early, mid-, and late K were provided by their K teachers blind to children's sleep histories, and by assessments administered by project staff.

RESULTS

Among the 3 sleep measures examined, regularity of nighttime sleep in which children slept 10 or more hours per night, especially at pre-K, consistently predicted more favorable K outcomes in both socioemotional, learning engagement, and academic domains. Results suggested that establishing healthy nighttime sleep habits before K start was especially promotive of better K adjustment across the full K year. These findings were controlled for income-to-poverty threshold ratios, child health status, and number of missed school days.

CONCLUSIONS

Efforts to promote a favorable transition to first-time schooling should pay particular attention to sleep hygiene and regularity of 10-plus hours of nightly child sleep established before the start of K.

Chronic insomnia of early childhood: Phenotypes and pathophysiology

This paper aims to review the limitations of the current classification of insomnia of early childhood and propose a new conceptual model allowing a better understanding of its pathophysiology. Our hypothesis is that chronic insomnia of childhood has different phenotypical expressions, associated to different pathophysiological mechanisms. Based on a long-lasting experience in evaluating a very large number of children with specific insomnia symptoms (nocturnal awakenings, difficulty in falling asleep, nocturnal restlessness, early morning awakenings) and on published data, we hypothesize that different phenotypes of insomnia might exist with different therapeutic implications. We describe three phenotypes of insomnia in early childhood: a) insomnia with motor restlessness; b) insomnia characterized without difficulties in falling asleep but with long-lasting early morning awakenings; c) insomnia with multiple night awakenings and falling asleep difficulty. This type of categorization might have important implications for treatment, based on the different hypothetical neurotransmitter dysfunctions. The early identification of a phenotype of insomnia might guide to specific behavioral and/or pharmacological interventions with the aim to prevent chronic insomnia.

Sleep Deficiency in Young Children

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.

Effectiveness of behavioral sleep interventions on children's and mothers' sleep quality and maternal depression: a systematic review and meta-analysis

This systematic review and meta-analysis was conducted to investigate the effectiveness of behavioral sleep interventions (BSIs) on the number of child night awakenings, and maternal sleep quality and depression. The search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) using PubMed, CINAHL, Cochrane, and EMBASE databases and retrieved studies published until April 2021. We calculated the odds ratios (ORs) and 95% confidence intervals (CIs) for child sleep problems, and the mean differences (MD) and 95% CI for the number of child night awakenings, and maternal sleep quality and depression. Ten studies of 1628 initial searched were included in the final analysis. Two of the 10 studies were divided into two subgroups by participants and intervention type; thus, 12 subgroups were included in the meta-analysis. BSIs significantly reduced child sleep problems (OR 0.51; 95% CI 0.37-0.69) and improved maternal sleep quality (MD - 1.30; 95% CI - 1.82 to - 0.77) in the intervention group. There were no significant differences in the number of child night awakenings and maternal depression between the two groups. More RCTs to examine the effect of BSIs considering children's age, duration of intervention, and outcome measuring time points are needed.

A retrospective study of eating and psychosocial problems in patients with hepatic glycogen storage diseases and idiopathic ketotic hypoglycemia: Towards a standard set of patient-reported outcome measures

There is a paucity in literature on eating and psychosocial problems in patients with hepatic glycogen storage disease (GSD) and idiopathic ketotic hypoglycemia (IKH), problems that can greatly affect quality of life. This is a monocentre, retrospective, observational mixed method study of patients with hepatic GSD or IKH treated at the Beatrix Children's Hospital Groningen, who had been referred to SeysCentra, a specialist centre for the treatment of eating problems. Additionally, a systematic literature review has been performed to identify instruments to quantify patient-reported outcome measures of psychosocial problems in hepatic GSD patients. Sixteen patients from 12 families were included with ages ranging between 3 and 24 years. Five out of sixteen patients were diagnosed with Avoidant/Restrictive Food Intake Disorder and six patients showed characteristics of this disorder. Fourteen patients experienced sleeping problems, and 11 out of 12 parent couples experienced stress about the illness of their child. We subsequently identified 26 instruments to quantify patient-reported outcome measures for GSD patients. This study demonstrates that GSD patients can develop Avoidant/Restrictive Food Intake Disorder influencing quality of life at multiple domains. The identification of instruments to assess psychosocial wellbeing is an important step towards a standard set of patient-reported outcome measures.

Association Between Sleep Disturbances With Neurodevelopmental Problems and Decreased Health-Related Quality of Life in Children With Fontan Circulation

Background Children with Fontan circulation are known to be at increased risk for neurodevelopmental problems and decreased health-related quality of life (HRQOL), but many factors that may contribute to this risk are unknown. Sleep disturbances may be one previously unidentified factor that contributes to this risk. Methods and Results We analyzed data from the Pediatric Heart Network Fontan cross-sectional study to evaluate associations between a parent or child report of sleep disturbance with reported neurodevelopmental concerns and HRQOL in 558 children with Fontan circulation. Parent-reported sleep disturbance was present in 11% of participants and child-reported sleep disturbance was present in 15%. Parent-reported sleep disturbance was associated with a significantly higher risk of attention problems, anxiety, depression, behavioral problems, and developmental delay (P<0.001 for all). Similarly, parent-reported disturbance was associated with decreased HRQOL on both parent and child-reported HRQOL (P<0.001 for most domains). Child-reported sleep disturbances were associated with increased odds of anxiety, depression, and attention problems as well as worse HRQOL. These associations were present even after adjustment for cardiac, demographic, and socioeconomic factors that may affect HRQOL and neurodevelopmental status. Conclusions Sleep disturbances in children with Fontan circulation are associated with an increased risk of neurodevelopmental problems as well as reduced HRQOL compared with those without sleep disturbance. Better understanding of sleep disturbances is needed in children with Fontan circulation, as sleep disturbances may represent a reversible cause of neurodevelopmental problems and decreased HRQOL in this population.

Sleep problems in preschool-onset major depressive disorder: the effect of treatment with parent-child interaction therapy-emotion development

In school-aged children, adolescents, and adults, more than 72% of individuals diagnosed with major depression report co-occurring sleep problems, but little is known about sleep problems in the context of preschool-onset major depressive disorder (PO-MDD). The current study examined the prevalence of various sleep problems in a sample of young children diagnosed with PO-MDD and explored how the treatment of depression, using a modification of parent-child interaction therapy focused on emotional development (PCIT-ED), affects sleep problems. Participants included 229 preschoolers (ages 3-6 years) who met criteria for PO-MDD and participated a single-blind, randomized control trial comparing PCIT-ED to a waitlist control condition. Children were randomly assigned to either PCIT-ED (n = 114) or the waitlist condition (n = 115). Children were assessed at baseline, immediately after PCIT-ED, and 3 months after treatment completion for parent-reported sleep problems across the domains of insomnia, hypersomnia, daytime fatigue, and a total sleep problem index. In our sample, 45% of children had at least one subthreshold sleep problem, 38.4% had at least one threshold sleep problem, and 72.5% had at least one sleep problem (either threshold or subthreshold). Treatment with PCIT-ED significantly reduced sleep problems, including insomnia, daytime fatigue, and total sleep problems, compared to a waitlist condition, even when controlling for child depression. This reduction was maintained at a 3-month follow-up. Sleep problems are a prevalent co-occurring condition with PO-MDD. Interventions such as PCIT-ED that also effectively reduce sleep problems may be particularly beneficial for recovery from PO-MDD.Clinical trial registration information: a randomized control trial of PCIT-ED for preschool depression; https://clinicaltrials.gov/NCT02076425 .

Associations Between Preschool Sleep Problems and Observed Dimensions of Elementary Classroom Engagement

Sleep has clear importance for academic success. However, most research in this area has focused on older children and adolescents and has used narrow measures of academic achievement, overlooking the importance of early sleep problems in shaping children's classroom behaviors that support academic success. Using a community sample (N = 276, 50% female), the current study examined associations between parent-reported preschool sleep problems (M _age = 3.84, SD = 0.83) and three dimensions of classroom engagement coded during live classroom observations in the first grade (M _age = 6.72, SD = 0.34). The moderating role of family socioeconomic status (SES) was also considered. A multivariate multilevel model found that more preschool sleep problems were associated with less focused engagement (defined as involvement in academic tasks, such as writing or asking questions), but more competing responses (defined as inappropriate or distracting behaviors). Preschool sleep problems were not associated with task management (defined as preparation for academic tasks, such as locating classroom materials). Although family SES did not moderate any of these associations, higher income-to-needs ratios in preschool were associated with more focused engagement and fewer competing responses. Findings highlight the role of early sleep problems in classroom behaviors that facilitate academic success. Targeting sleep problems prior to the school transition may serve as a useful approach to optimizing learning conditions during this key developmental period.

Sleep problems, internalizing and externalizing symptoms, and domains of health-related quality of life: bidirectional associations from early childhood to early adolescence

STUDY OBJECTIVES

To examine longitudinal, bidirectional associations among behavioral sleep problems, internalizing and externalizing symptoms, and domains of health-related quality of life (HRQoL) from early childhood to adolescence in a population sample of Australian children.

METHOD

Data were drawn from the Longitudinal Study of Australian Children, a national prospective cohort study with 4983 children participating in the Kindergarten cohort. Data were collected when children were aged 4-5, 6-7, 8-9, 10-11, and 12-13 years. At each study wave, the primary parent (97% mothers) reported on behavioral child sleep problems, internalizing and externalizing symptoms, and HRQoL domains (psychosocial and physical). Cross-lagged structural equation models were used to evaluate bidirectional associations.

RESULTS

At nearly every age, behavioral sleep problems were associated with worse subsequent psychosocial and physical HRQoL. Despite bidirectional associations between mental health and HRQoL at many waves, HRQoL domains more strongly predicted later internalizing symptoms, while externalizing symptoms more strongly predicted later HRQoL. Many of the bidirectional associations among sleep, mental health, and HRQoL were found earlier in childhood.

CONCLUSIONS

Behavioral sleep problems may forecast later HRQoL psychosocial and physical impairments. Attending to both sleep problems and HRQoL could prevent the progression of internalizing conditions, while a focus on externalizing concerns could prevent the worsening of these symptoms, sleep problems, and HRQoL, particularly during the transition to school.

Cumulative socio-demographic risk factors and sleep outcomes in early childhood

STUDY OBJECTIVES

To examine associations between cumulative socio-demographic risk factors, sleep health habits, and sleep disorder symptoms in young children.

METHODS

Two hundred five caregiver-child dyads (child mean age ± SD: 3.3 ± 1.1 years; 53.7% girls; 62.9% black, 22.4% non-Hispanic/Latinx white, 4.4% Hispanic/Latinx; 85.4% maternal caregiver reporter) completed caregiver-rated sleep measures (Brief Child Sleep Questionnaire [BCSQ]; Pediatric Sleep Questionnaire [PSQ] snoring subscale), which were used to generate indexes of poor sleep health habits, pediatric insomnia symptoms, and obstructive sleep apnea (OSA) symptoms. A cumulative risk index was created reflecting caregiver, family, and neighborhood risks.

RESULTS

Overall, 84.5% of children had ≥ 1 poor sleep health habit, 62.9% had ≥ 1 insomnia symptom, and 40.0% had ≥ 1 OSA symptom. Poisson regression indicated that each increase in the number of cumulative risk factors was associated with a 10% increase in poor sleep health habits, a 9% increase in insomnia symptoms, and an 18% increase in OSA symptoms. Specific caregiver risks (depressive symptoms, lower educational attainment) and family risks (single caregiver, crowded home) were most predictive of poor sleep outcomes.

CONCLUSIONS

Poor sleep health habits and sleep disorder symptoms are highly prevalent in early childhood, particularly among families experiencing cumulative socio-demographic risks. Findings underscore the need for targeted screening and prevention for modifiable sleep behaviors and efforts to tailor such strategies for at-risk children and families, especially those living in crowded conditions, or with caregivers who are single or have a lower educational attainment or depressive symptoms.

The Role of Sleep in Young Children's Development: A Review

This review article provides an overview of studies highlighting the importance of sleep in young children's development and summarizes research-based strategies for implementing healthy sleep practices. Sleep problems are common among young children and is one of the most commonly expressed concerns reported by caregivers. Insufficient sleep, poor sleep quality, and irregular sleep schedules may affect children's physical health, cognitive capacity, socioemotional processes, and behavioral functioning, with implications for children's development and well-being. Family context and factors, confounded with cultural variables, play a critical role in children's sleep behavior and practices. This article presents research-based recommendations to enhance knowledge about children's sleep and to promote appropriate practices.

Paediatric sleep literacy in australian health professionals

OBJECTIVE

This study aimed to provide the first estimate of sleep knowledge, practices, and attitudes regarding paediatric sleep in Australian health professionals.

METHODS

263 Australian health professionals (medical practitioners, nurses, psychologists, social workers, occupational therapists, pharmacists, dentists and sleep coaches) completed an anonymous survey.

RESULTS

Clients with sleep disorders were commonly encountered by health professionals, yet professionals reported little time spent on clinical training in sleep medicine at the undergraduate (∼1-5 hrs) or postgraduate (∼0.5-3.5 hrs) level. Health professionals reported seeking continuing professional development (CPD) in sleep (∼6+ hrs), and CPD had the most influence on health professionals' practice, relative to other sources of information. Over half of health professionals (∼56-58%) reported that they were not trained in sleep measurement (i.e., sleep diaries and questionnaires), or how to take a sleep history. On average, professionals answered less than half (44.5%) of paediatric sleep knowledge questions correctly (M = 13.35, SD = 6.03). Approximately one third of health professionals reported not routinely screening for sleep disorders in paediatric patients and many did not routinely recommend evidence based treatments. The impact and importance of paediatric sleep was well recognised, but sleep was considered less important than a healthy diet and exercise.

CONCLUSIONS

Results from the current study highlight key knowledge gaps regarding paediatric sleep across a wide range of Australian health professions, and may inform future efforts to reform clinical sleep medicine training in Australia.

Sleep disordered breathing in children: which symptoms do parents consider a problem?

STUDY OBJECTIVE

Parents tend to under-report symptoms suggestive of sleep disordered breathing (SDB) at medical consultation. It is thought that a contributing factor may be whether parents view SDB symptoms as a problem. The aim of the study was to examine to what extent parents view SDB symptoms as a problem in children recruited from the general community and especially in children who currently have symptoms suggestive of SDB.

METHODS

Parents of 1639 children aged 5-10 y attending middle school in South Australia completed a questionnaire which included demographics and assessed the frequency over the previous school week of 32 sleep habits including six SDB sleep habit items. The sample was restricted to typically developing children and excluded children with medical problems likely to impact SDB. The final sample included 1610 children without a prior diagnosis of SDB and 29 with a prior diagnosis and/or treatment of SDB. Parents were asked to rate children's sleep habits using a 4-pt scale (never, rarely, sometimes and usually) and if the sleep habit was perceived to be a problem (yes/no). Children who sometimes or usually reported a sleep habit item were labelled as symptomatic.

RESULTS

Parents of children with, compared to those without, a prior diagnosis of SDB, were more likely to report the presence of SDB symptoms which were more frequently viewed as a problem. In children without a prior diagnosis of SDB, parents of symptomatic children viewed most SDB symptoms as a problem ranging from 91% for apnoea, 63% snorted/gasped, 63% watched child breathing at night, 58% snored loudly, 49% snored to 32% breathing heavily at night. Additional analyses in the combined sample revealed that a prior diagnosis of SDB, gender, socioeconomic status and ethnicity were weak predictors of whether parents viewed SDB sleep symptoms as a problem.

CONCLUSION

In children with symptoms suggestive of SDB, most parents viewed most SDB symptoms as a problem especially apnoea. The high frequency is contrary to that expected given the under-reporting of SDB symptoms at medical consultation. This suggests that additional factors other than whether parents consider SDB symptoms as a problem might better explain the under-reporting of SDB symptoms at medical consultation. Given the important impact on child health and medical service provision, future studies examining the factors that prompt parents to discuss SDB symptoms at medical consultation are warranted.

Emergent academic skills growth in New Zealand pre-school children undergoing treatment for sleep disordered breathing: a case-control pilot study

OBJECTIVES

The main objective of this study was to explore the feasibility and treatment sensitivity of measures of preschool oral language and emergent literacy and numeracy for assessing developing skills of preschool children with sleep disordered breathing (SDB) in New Zealand following adenotonsillectomy.

METHODS

Eight preschool children aged 3 years 1 month-4 years 5 months were recruited from a surgical waiting list and matched to controls for age (±3 months) and sex. Tasks designed to be sensitive to growth in oral language and emergent literacy and numeracy were reviewed for contextual fit, adapted as necessary for the New Zealand context, and administered before surgery (baseline), three months post-surgery, and at a seven-month follow-up alongside other measures.

RESULTS

Growth in oral language and emergent literacy was greater for case children than matched controls, suggesting that the tasks were sensitive to treatment effects. No such effect was observed for early numeracy tasks. Case children had more symptoms of SDB and behavioral and emotional difficulties than matched controls prior to surgery, and improvements were reported in these domains following surgery.

CONCLUSIONS

Oral language and emergent literacy measures trialled in the present research showed potential for evaluating treatment outcomes in pre-schoolers with SDB, and provided preliminary evidence that early treatment of SDB could have positive effects on learning in these domains.

Sleep Well Be Well: Pilot of a digital intervention to improve child behavioural sleep problems

AIM

To investigate whether a digital sleep intervention improves child and care giver sleep and psychosocial outcomes.

METHODS

A total of 120 families with children aged 2-13 years, reporting moderate to severe child behavioural sleep problems, were recruited from a hospital sleep clinic waitlist or the community. Children from non-English speaking families, with known intellectual disability (IQ < 70) or severe medical problems excluded. Tailored behavioural sleep strategies were delivered to primary care givers via a smart phone app and complementary website. Eligible families completed a baseline questionnaire and child 'sleep check' then received the digital sleep intervention for 5 weeks, and then completed a post questionnaire.

OUTCOMES

care giver report of child sleep as no/mild versus moderate/severe problem over past month (primary outcome); problem child sleep patterns (Brief Infant Sleep Questionnaire or Child Sleep Habits Questionnaire), child temperament, care giver mental health (Kessler 6), care giver sleep, health service use for their child's sleep and time off work/activities to access services.

RESULTS

At follow up, care givers reported fewer moderate/severe child sleep problems (84.6-40.7%), improved problem child sleep patterns, better temperament and improved care giver mental health. Care giver sleep quality and quantity remained unchanged. Health service use (averaged over a 6-month period pre- and post-intervention) fell from 18.9% pre- to 14.1% post-intervention.

CONCLUSION

A digital sleep intervention appears promising in improving sleep in children with moderate/severe behavioural sleep problems, and care giver mental health. It may be a useful alternative to face-to-face management of behavioural sleep problems.

Does the Psychopathology of the Parents Predict the Developmental-Emotional Problems of the Toddlers?

Introduction

Parental psychopathology has been defined in respect of psychopathological development in early childhood. This study aimed to investigate the effects of parental psychopathologies on social and emotional problems in the age range of 1-3 years and to determine children at risk.

Methods

The study data were obtained from the 2009 Early Childhood Mental Health Profile taking population distribution into consideration with the properties representing Turkey. The primary caregiver of the child completed the Psychiatric Evaluation Form for 1-3 years, the Brief Infant-Toddler Social Emotional Assessment (BITSEA), the Ages and Stages Questionnaire (ASQ), and the Brief Symptom Inventory (BSI) for themselves. Machine learning models used for prediction. The performance of prediction models was evaluated with the ten-fold cross-validation method. Area Under Curve (AUC) values were calculated with Receiver Operating Characteristic (ROC) curves to evaluate the performance of each model.

Results

The evaluation was made of the data of 2775 children, comprising 1507 (54.3%) males and 1268 (45.7%) females with a mean age of 26.19±9.11 months (range, 10-48 months). A total of 106 children were identified as at risk, as they were above the clinical cut-off point (1.5 standard deviations) of the BITSEA points and below the cut-off points of any one of the developmental areas of the ASQ. Modeling was applied to the data of these 106 children. The Support Vector Machines (SVM) model was selected for prediction with the automatically optimized highest AUC value. Weighting for the SVM algorithm showed mothers' BSI scores, fathers' education and health problems, duration of breastfeeding, unplanned pregnancy are significant for predicting BITSEA-problem scores in the model.

Conclusion

To be able to understand the complex relationship with parental psychopathology and behavioral problems, machine learning methods were used successfully in this study. Further studies with more massive data sets, more extended follow-up periods, and stronger algorithms will be able to identify risk groups earlier and allow early interventions to be implemented.

Promoting Independent Sleep Onset in Young Children: Examination of the Excuse Me Drill

Background: There is compelling evidence to support behavioral interventions as the first-line approach for bedtime resistance in young children. Among the behavioral treatment options, extinction ("cry it out") has the most extensive empirical support and tends to produce the most rapid gains. There are well known problems with the use of extinction, however, including side effects (extinction burst, spontaneous recovery) and poor acceptance, not to mention that extinction fails to teach children appropriate replacement behaviors (what "to do"). This study introduces a new behavioral sleep intervention, the Excuse Me Drill, designed to address some of the limitations of extinction. The EMD was formally evaluated for the first time using a multiple-baseline research design across four participants with sleep disturbance.Participants: Participants included four children who were clinically referred to outpatient pediatric psychology clinics for the treatment of behavioral insomnia of childhood, and included one 2-year-old female, two 7-year-old females, and one 7-year-old male. All participants had a history of dependent sleep onset at bedtime (i.e., parents remained in the child's bedroom upon sleep onset). Methods: A non-concurrent multiple baseline design across participants was used to experimentally evaluate the effectiveness of the EMD. During baseline, parents collected data on independent sleep onset and disruptive bedtime behaviors, but conducted the bedtime routine as usual. Immediately following baseline, parents implemented the EMD protocol until data indicated that children were consistently initiating sleep independently. Follow-up data were collected to determine the extent to which children continued to initiate sleep independently at bedtime in absence of the EMD. Results: Outcomes were promising as the EMD successfully taught all four children to initiate sleep independently and produced notable decreases in disruptive bedtime behavior. Results were maintained at follow-up for three of four participants. In addition, parents rated the EMD to be a socially acceptable procedure for their children. Conclusions: Results of this study indicate that the EMD was effective in promoting independent sleep onset and reducing disruptive bedtime behavior that maintained over time. The EMD should be considered to be a viable alternative to traditional extinction procedures for pediatric sleep disturbance. Implications for practice, limitations, and direction for future research are discussed.

Sleep timing and sleep problems of preschoolers in Aotearoa/New Zealand: relationships with ethnicity and socioeconomic position

OBJECTIVES

To provide descriptive sleep data and explore sleep inequities, we investigated maternal reports of when and how well Māori (Indigenous) and non-Māori preschoolers sleep, and examined relationships between ethnicity (child and maternal), socioeconomic position (SEP) and sleep timing and problems of 3-4 year old children in Aotearoa/New Zealand (NZ).

METHODS

This study involved cross-sectional analysis of data from the Moe Kura: Mother and Child, Sleep and Wellbeing in Aotearoa/New Zealand longitudinal study. Log-binomial regression models were used to investigate associations between child and maternal demographic variables and preschooler bedtimes, social jetlag and maternally-reported sleep problems. Child models included child ethnicity, child gender, area- and individual-level deprivation. Maternal models included maternal ethnicity, maternal age, area- and individual-level deprivation.

RESULTS

340 Māori and 570 non-Māori preschoolers and their mothers participated. Māori preschoolers had later average bedtimes and wake times than non-Māori preschoolers. Ethnicity and area-level deprivation were independently associated with later bedtimes. Ethnicity was associated with social jetlag and sleep problems, independent of SEP. Individual-level deprivation was associated with problems falling asleep. Preschoolers of Māori mothers in least deprived areas were more likely to have problems falling asleep than preschoolers of non-Māori mothers in least deprived areas.

CONCLUSIONS

Research is needed to understand what sleep timing differences mean for preschoolers' wellbeing in NZ. Fundamental causes of social and economic disadvantage experienced by Indigenous children and mothers and by families who hold low SEP must be addressed, in order to eliminate sleep health inequities in early childhood.

Associations Between Child Sleep Problem Severity and Maternal Well-Being in Children with Autism Spectrum Disorder

This study investigated whether sleep problem severity in children with autism spectrum disorder was associated with maternal well-being. Mothers of 234 children reported on their mental health (Kessler Psychological Distress Scale), parenting stress (Parenting Stress Index-4-SF), health-related quality of life (HRQoL; Assessment of Quality of Life-4D) and their child's sleep (Children's Sleep Habits Questionnaire-ASD). Analyses revealed sleep initiation and duration problem severity scores were associated with increased mental health difficulties. Specific child sleep problems were not associated with parenting stress or HRQoL. This study revealed the importance of considering sleep and the family system when assessing maternal well-being. Future research considering parent, child and family factors will be important to informing a family focused approach to mental health.

Sleep across early childhood: implications for internalizing and externalizing problems, socioemotional skills, and cognitive and academic abilities in preschool

BACKGROUND

Sleep is thought to be important for behavioral and cognitive development. However, much of the prior research on sleep's role in behavioral/cognitive development has relied upon self-report measures and cross-sectional designs.

METHODS

The current study examined how early childhood sleep, measured actigraphically, was developmentally associated with child functioning at 54 months. Emphasis was on functioning at preschool, a crucial setting for the emergence of psychopathology. Participants included 119 children assessed longitudinally at 30, 36, 42, and 54 months. We examined correlations between child sleep and adjustment across three domains: behavioral adjustment (i.e., internalizing and externalizing problems), socioemotional skills, and academic/cognitive abilities. We further probed consistent associations with growth curve modeling.

RESULTS

Internalizing problems were associated with sleep variability, and cognitive and academic abilities were associated with sleep timing. Growth curve analysis suggested that children with more variable sleep at 30 months had higher teacher-reported internalizing problems in preschool and that children with later sleep timing at 30 months had poorer cognitive and academic skills at 54 months. However, changes in sleep from 30 to 54 months were not associated with any of the domains of adjustment.

CONCLUSIONS

Findings indicate that objectively measured sleep variability and late sleep timing in toddlerhood are associated with higher levels of internalizing problems and poorer academic/cognitive abilities in preschool.

Interventions to control children's screen use and their effect on sleep: A systematic review and meta-analysis

Prolonged viewing of screen-based media is associated with poor sleep in children. Previous systematic reviews have analysed the effectiveness of interventions that aim to limit children's screen use; however, none have evaluated its effect on sleep. The aim of this systematic review was to evaluate the effect of interventions that incorporate strategies to control children's screen use on screen use and sleep. The databases Pubmed, Embase, Eric, Scopus and PsycInfo were searched during October 2017 and updated in February 2019 for experimental studies with a control that assessed interventions to control screen use in children aged 2-14 years and reported both screen use and sleep outcomes. From 3,872 initial records, 11 studies (six randomized control [RCT], four cluster RCT and one cluster, quasi-experimental) were eligible for inclusion. A total of 4,656 children aged 2-13 years were included in the studies. The mean reduction in screen time was 0.56 hr (33 min)/day (95% confidence interval [CI], 0.92, 0.20) and the mean sleep duration increased by 0.19 hr (11 min)/day (95% CI, 0.05, 0.33). Bedtime was advanced by 0.16 hr (10 min) on weekdays and by 1.0 hr at the weekend. Subgroup analyses indicated stronger intervention effects for interventions of shorter duration (<3 months), which specifically targeted screen use or sleep, and those with direct participant contact. In conclusion, small improvements in screen time and sleep duration can be achieved in children. It is not possible to determine if a reduction in screen time directly improves sleep, due to the limited number of studies, the presence of co-interventions, issues with studies' methodological quality and heterogeneity.

Prevalence and Comorbidity of Atopic Dermatitis in Children: A Large-Scale Population Study Based on Real-World Data

This study aimed at exploring atopic dermatitis (AD) prevalence in children and exhaustively analyzing their comorbidity. We conducted a descriptive analysis of their socio-demographic and comorbidity characteristics in the EpiChron Cohort (Aragón, Spain). Adjusted odds ratios (OR) were calculated for each comorbidity using logistic regression models. In total, 33,591 children had a diagnosis of AD, resulting in an overall prevalence of 15.5%. AD prevalence was higher in girls compared to boys, in 3–9-year-olds compared to children of other ages, and in Spanish children compared to those of other nationalities. Multimorbidity was present in 43% of children, with the most frequent chronic comorbidities being asthma (13.1%), psychosocial disorders (7.9%), and visual impairment (7.8%). Many diseases were, regardless of their prevalence, statistically associated with AD. The strongest associations (odds ratio (OR) (95% confidence interval (CI))) were found in asthma (2.10 (2.02–2.17)), allergic rhinitis (2.00 (1.91–2.10)), and irritable bowel syndrome (1.90 (1.56–2.31)). A better understanding of the array of comorbidities associated with AD in children might help improve their clinical management. Future longitudinal studies are encouraged to shed light on the potential underlying pathophysiological mechanisms involved in the identified associations.

Executive functions in preschool children with chronic insomnia

STUDY OBJECTIVES

Executive functions (EFs) in children with insomnia have not been sufficiently assessed in the literature. This study aimed to describe sleep patterns and habits and EF abilities in preschool children with insomnia, compared to healthy control patients, and to evaluate the relationships between sleep patterns and EFs.

METHODS

Two groups of children were recruited: 45 preschoolers with chronic insomnia (28 boys), aged 24-71 months and 167 healthy preschool children (81 boys) aged 24-71 months. Parents of all children completed two questionnaires to assess their children's sleep habits and disturbances, and their EFs with the Behavior Rating Inventory of Executive Function - Preschool Version.

RESULTS

Children with chronic insomnia were found to wake up earlier, sleep less during the night, have more nighttime awakenings, and higher nocturnal wakefulness, compared to the control group. The chronic insomnia group showed significant impairment in all the EFs domains. Nocturnal sleep duration, nighttime awakenings, and nocturnal wakefulness correlated with inhibit, plan/organize, working memory, inhibitory self-control, emergent metacognition, and the global executive composite scores in the chronic insomnia group. In the control group, the number of nighttime awakenings correlated with inhibition, inhibitory self-control, and the global executive composite. Regression analyses showed a predominant role of insomnia factor in the association with EFs in both clinical and control groups.

CONCLUSIONS

Our findings confirm the link between sleep and "higher level" cognitive functioning. The preschool period represents a critical age during which transient sleep problems also might hamper the development of self-regulation skills and the associated neural circuitry.

Parental Cognitions About Sleep Problems in Infants: A Systematic Review

Introduction: Parental cognitions may directly and indirectly contribute to infant sleep outcomes. This review provides a systematic up-to-date overview of the associations between parental cognitions and infant sleep problems with special emphasis on temporal relationships and the content of parental cognitions. Methods: A systematic literature research in PubMed and Web of Science Core Collection sensu Liberati and PRISMA guidelines was carried out in March 2020 using the search terms (parent^* AND infant^* AND sleep^* problem^*), including studies with correlational or control group designs investigating associations between parental cognitions and sleep problems in children aged 1-6 years. Results: Twenty-three studies (published from 1985 to 2016) met inclusion criteria, of which 14 reported group differences or associations between parental sleep-related cognitions and child sleep outcomes. Nine papers additionally reported on the role of general parental child-related cognitions not directly pertaining to sleep. Findings from longitudinal studies suggest that parental cognitions often preceded child sleep problems. Cognitions pertaining to difficulties with limit-setting were especially prevalent in parents of poor sleepers and were positively associated with both subjective and objective measures of child sleep outcomes. Conclusions: Parental cognitions appear to play a pivotal role for the development and maintenance of sleep problems in young children, arguing that parents' attitudes and beliefs regarding child sleep inadvertently prompts parental behavior toward adverse sleep in offspring. Associations are however based on maternal reports and small to moderate effect sizes. Thus, additional parental factors such as mental health or self-efficacy, as well as additional offspring factors including temperamental dispositions and regulatory abilities, require consideration in further studies.

"Their Sleep Means More Harmony": Maternal Perspectives and Experiences of Preschoolers' Sleep in Ethnically and Socioeconomically Diverse Families in Aotearoa/New Zealand

Viewing sleep through a socioecological lens, maternal perceptions, and experiences of preschoolers' sleep were explored using semistructured interviews with 15 Māori (indigenous) and 16 non-Māori mothers, with low- and high socioeconomic position. Thematic analysis identified four themes: child happiness and health, maternal well-being, comfort and connection, and family functioning and harmony. Mothers perceived healthy preschooler sleep as supporting children's mental and physical health, parents' sleep/wake functioning, family social cohesion and emotional connectedness, and poor preschooler sleep as negatively influencing child, maternal and family well-being. Although many experiences were shared, some perceptions of sleep and sleep practices differed between mothers. Influences included health paradigms, socioeconomic circumstances, maternal autonomy, employment, parenting approaches, and societal expectations. Healthy preschooler sleep is valued by mothers and may play a protective role in family health and resilience. Preschooler sleep initiatives need to be responsive to maternal perspectives and address societal drivers of sleep experiences.