Sleep, screen time and behaviour problems in preschool children: an actigraphy study.

Inadequate sleep and excessive exposure to media screens have both been linked to poorer mental health in youth. However, the ways in which these interact to predict behaviour problems have yet to be examined using objective sleep measurement. The lack of objective evidence for these relationships in young children has recently been defined by the World Health Organization (2019) as a gap in the field. We thus aimed to test the interacting effects of screen exposure and objectively measured sleep on behaviour problems in the preschool age. A total of 145 children aged 3-to-6-years participated in this cross-sectional study. Sleep was assessed objectively using actigraphy for 1-week, and subjectively using parent-reported daily sleep diaries. Parents reported the child's daily duration of screen exposure, and completed the Strengths and Difficulties Questionnaire. Results showed that actigraphic sleep duration, timing and efficiency were associated with screen exposure. The link between screen time and behaviour problems was moderated by sleep duration, as it was significant only for children with sleep duration of 9.88 h or less per night. Sleep duration also moderated the relation between screen time and externalizing-but not internalizing-problems. Hence, the combination of increased screen exposure and decreased sleep duration may be particularly adverse for child mental health. While these key relationships should be further examined in longitudinal and experimental investigations, our findings shed light on their complexity, underscoring the importance of the moderating role of sleep.

Sleep and Social-Emotional Development in Infants and Toddlers.

The aim of this study was to examine the cross-sectional and longitudinal relationships among variables related to sleep patterns and both social-emotional problems (i.e., internalizing, externalizing, and dysregulation) and healthy social development (i.e., social competence). Assessments were completed at 6, 12, and 18 months across 5 cohorts of children for a total of 117 mother-child dyads. Mothers completed the Brief Infant Sleep Questionnaire at 6, 12, and 18 months, as well as the Infant Toddler Social Emotional Assessment at 12 and 18 months. Later bedtimes and less total sleep across the 24-hr period predicted higher internalizing problem scores, which includes indices of depression/withdrawal, general anxiety, separation distress, and inhibition. In contrast, sleep fragmentation was minimally associated with decreased social competence but not with any negative social-emotional outcomes. These results indicate that sleep patterns, primarily later bedtimes and less total sleep, appear to be associated with and predictive of social-emotional problem areas, namely, internalizing issues, in infants and toddlers. These findings add to the growing literature on the role of sleep in early social-emotional development and suggest that sleep schedule and duration should be addressed in clinical assessment and interventions for infant sleep.

Annual Research Review: Sleep problems in childhood psychiatric disorders--a review of the latest science.

BACKGROUND: Hippocrates flagged the value of sleep for good health. Nonetheless, historically, researchers with an interest in developmental psychopathology have largely ignored a possible role for atypical sleep. Recently, however, there has been a surge of interest in this area, perhaps reflecting increased evidence that disturbed or insufficient sleep can result in poor functioning in numerous domains. This review outlines what is known about sleep in the psychiatric diagnoses most relevant to children and for which associations with sleep are beginning to be understood. While based on a comprehensive survey of the literature, the focus of the current review is on the latest science (largely from 2010). There is a description of both concurrent and longitudinal links as well as possible mechanisms underlying associations. Preliminary treatment research is also considered which suggests that treating sleep difficulties may result in improvements in behavioural areas beyond sleep quality. FINDINGS: To maximise progress in this field, there now needs to be: (a) greater attention to the assessment of sleep in children; (b) sleep research on a wider range of psychiatric disorders; (c) a greater focus on and examination of mechanisms underlying associations; (d) a clearer consideration of developmental questions and (e) large-scale well-designed treatment studies. CONCLUSIONS: While sleep problems may sometimes be missed by parents and healthcare providers; hence constituting a hidden risk for other psychopathologies - knowing about these difficulties creates unique opportunities. The current excitement in this field from experts in diverse areas including developmental psychology, clinical psychology, genetics and neuropsychology should make these opportunities a reality.

Low parental tolerance for infant crying: an underlying factor in infant sleep problems?

Parenting behaviours play a major role in the evolution of infant sleep. Sleep problems in infancy have been associated with excessive parental involvement at night-time, and with shorter delays in response to infant night wakings and signalling. Infant crying and sleep problems are linked, yet little is known about the impact of parental responses to crying on infant sleep patterns. This study examined the hypothesis that lower parental tolerance for crying is associated with infant sleep problems. We studied 144 married couples divided into three groups: parents of infants suffering from night-waking problems (i.e. the clinical group), parents of infants without sleep problems and childless couples. Crying tolerance was assessed using questionnaires, audio recordings of crying infants and using a novel paradigm, in which participants were shown a video of a crying infant and asked when they would intervene. Parents in the clinical group demonstrated shorter intervention delays in the crying infant clip (group effect: P < 0.0001), and tended to attribute more distress to the crying infants compared to parents in both control groups (P < 0.05). Additionally, women demonstrated lower tolerance for infant crying on most measures compared to men. Our results suggest that parents of sleep-disturbed infants appear to have lower tolerance for infant crying, which may be a predisposition underlying their excessive involvement in soothing their infants to sleep which may lead to the development of sleep problems. These preliminary findings should be explored further to assess their clinical validity and utility.

Sleep Patterns among South Korean Infants and Toddlers: Global Comparison.

The purpose of this study was to examine sleep patterns in a large sample of infants and toddlers (ages birth to 36 months) in Korea, and to compare sleep patterns, sleep problems, sleep ecology, and parental behaviors to global sleep data on young children in both predominantly Asian (P-A) and predominantly Caucasian (P-C) countries/regions. We additionally examined parent and child demographic information, parental behaviors, and aspects of the sleep ecology as predictors of sleep patterns among infants and toddlers in Korea. Parents/caregivers of 1,036 Korean infants and toddlers completed an expanded, internet-based version of the brief infant sleep questionnaire. Consistent with other studies of sleep in early childhood, sleep/wake patterns became increasingly consolidated with older child age for the Korea sample. Compared to both P-A and P-C infants and toddlers, children in Korea had the latest bedtimes, shortest total sleep and daytime sleep durations, and the least frequent rates of napping. Even though half of parents perceive their children's sleep problematic, parental perceptions of severe child sleep problems were the lowest. Within Korea, breastfeeding and bottle-feeding at sleep resumption were associated with increased nocturnal awakenings. Evening television viewing was associated with later bedtimes, which may have implications for sleep hygiene recommendations in clinical practice. The current study provides important information about sleep/wake patterns, parental behaviors, and aspects of the sleep ecology for infants and toddlers for physicians to support healthy sleep in Korea.

Relationship Between Child and Maternal Sleep: A Developmental and Cross-Cultural Comparison.

The aim of this study was to assess the relationship between young children's sleep and maternal sleep from both a developmental and a cross-cultural perspective. Mothers of 10,085 young children completed the Brief Infant/Child Sleep Questionnaire and the Pittsburgh Sleep Quality Index. Overall, there were significant relationships between maternal and child sleep for bedtime, waketime, number of night wakings, and total nighttime sleep time across ages and cultures, although these relationships were stronger with younger children than preschool-aged children. Mothers report that their child's sleep pattern significantly impacts their sleep and daytime function, and they do not feel confident in managing their child's sleep pattern. Thus, interventions to improve children's sleep and develop good sleep habits, especially in early childhood, are likely to improve the quality of life of the whole family.

Iii. Sleep assessment methods.

Sleep is a complex phenomenon that could be understood and assessed at many levels. Sleep could be described at the behavioral level (relative lack of movements and awareness and responsiveness) and at the brain level (based on EEG activity). Sleep could be characterized by its duration, by its distribution during the 24-hr day period, and by its quality (e.g., consolidated versus fragmented). Different methods have been developed to assess various aspects of sleep. This chapter covers the most established and common methods used to assess sleep in infants and children. These methods include polysomnography, videosomnography, actigraphy, direct observations, sleep diaries, and questionnaires. The advantages and disadvantages of each method are highlighted.

I. Sleep and development: introduction to the monograph.

Literature on sleep and child development is growing rapidly in exciting new directions across several disciplines and with this comes a need for guiding conceptual principles and methodological tools. In this introductory chapter, the importance of sleep for child development across multiple domains is highlighted. The aims of this monograph are presented and pertain to the need to consider and integrate theory and research across multiple disciplines and use state-of-the-art methodologies. A developmental ecological systems perspective adapted to sleep illustrates the multiple levels of influence and their importance in the study of child sleep and development. A focal aim is to provide examples of longitudinal studies linking sleep with child development, which are presented in seven chapters of this volume.

Xi. Sleep and development: conclusions and future directions.

Literature on sleep and child development is growing in novel directions across several disciplines necessitating guiding conceptual principles and methodological tools. First, this volume presents a summary of discussions from an SRCD-sponsored multidisciplinary forum on sleep and development, which includes presentation of key issues and guiding recommendations for research priorities in this fast developing field. Second, enhancing accessibility to child development researchers, state of the science sleep assessment methodologies are presented with a discussion of their advantages and disadvantages. Third, seven empirical studies conducted with "typically" developing infants and children provide examples of relations between sleep and some of the many individual and familial factors that influence and are influenced by sleep. In the presentation of empirical findings, a developmental ecological systems perspective adapted to sleep was espoused to illustrate some of the multiple levels of influence in the study of child sleep and development. Collectively, studies in this volume build significantly on the literature through: (a) illustrating linkages between various sleep parameters (e.g., quality, sleeping arrangements) and other key developmental domains (e.g., attachment, parenting); (b) demonstration of longitudinal relations connecting sleep with development, which is scarce in this field; and (c) utilization of actigraphy-based assessments of sleep duration and quality, which are underutilized in the literature yet important for a more nuanced understanding of sleep and development.

Infant sleep development from 3 to 6 months postpartum: links with maternal sleep and paternal involvement.

The aims of this longitudinal study were to examine (a) development of infant sleep and maternal sleep from 3 to 6 months postpartum; (b) concomitant and prospective links between maternal sleep and infant sleep; and (c) triadic links between paternal involvement in infant caregiving and maternal and infant sleep. The study included 57 families that were recruited during pregnancy. Maternal and infant sleep was assessed using actigraphy and sleep diaries for 5 nights. Both fathers and mothers completed a questionnaire assessing the involvement of fathers relative to mothers in infant caregiving. The results demonstrated moderate improvement in infant and maternal sleep percent between 3 and 6 months. Maternal sleep percent at 3 months significantly predicted infant sleep percent at 6 months. Greater paternal involvement in infant daytime and nighttime caregiving at 3 months significantly predicted more consolidated maternal and infant sleep at 6 months. These findings suggest that maternal sleep is an important predictor of infant sleep and that increased involvement of fathers in infant caregiving responsibilities may contribute to improvements in both maternal and infant sleep during the first 6 months postpartum.

Reactivity and sleep in infants: a longitudinal objective assessment.

Sleep patterns and temperament in the first year of life are closely related. However, research utilizing objective, rather than subjective measurements of sleep and temperament is scarce and results are inconsistent. In addition, a relative lack of longitudinal data prevents inference of causality between the two constructs. In this study, infant sleep was objectively assessed among 95 infants at 3, 6, and 12 months-of-age with an actigraph in the home setting. Reactivity to sound, light, and touch, a specific aspect of temperament, was behaviorally assessed at 3 and 6 months, both during sleep (at home) and during waking (at the laboratory). Expected maturational trends were recorded in sleep, with a temporal increase in sleep efficiency and percent of motionless sleep. Quadratic (i.e., inverse U shape) relations were found, especially among girls, when predicting change in sleep by reactivity thresholds, suggesting that both hyposensitive and hypersensitive infants are at risk for poor sleep quality. These are the first research findings suggesting that low reactivity in infancy might be associated with compromised sleep quality. The observed nonlinear effects may account for null or inconsistent results in previous studies that explored only linear associations between temperament and sleep. Future studies should address both extremes of the temperament continuum when exploring relations with sleep patterns.

Nighttime fears of preschool children: a potential disposition marker for anxiety?

OBJECTIVE: To examine if children who suffer from significant Nighttime Fears (NF) experience higher degree of general fears and behavioral problems and to explore whether effortful control mediates NF association with internalizing problems. METHODS: One-hundred and nine preschool children (64 boys) between the ages 4 and 6years suffering from significant NF and 30 healthy children (16 boys) were evaluated using parental reports of behavioral problems [Child Behavior Checklist (CBCL)], parental and child report of fears [Fear Survey Revised for Parents (FSS-PC), Koala Fear Questionnaire (KFQ)], and a measure of effortful control derived from the Child Behavior Questionnaire (CBQ). RESULTS: Children with severe NF also suffer from an increased level of a wide variety of fears other than NF, and exhibit more behavioral problems than controls both on parental and children's measures of general fears, and main CBCL scale scores (Internalizing, Externalizing, Total score). Additionally, children with NF had lower abilities of effortful control (as manifested in CBQ attention and inhibitory control scales). Attention control mediated NF association to internalizing problems scale. CONCLUSIONS: NF may serve as a marker for anxiety vulnerability, and this vulnerability might be mediated by abnormal attentional control. Our finding also highlights the need for a more comprehensive assessment of behavioral problems, fears and anxiety phenomena among children referred with NF.

Income, ethnicity, and sleep: coping as a moderator.

Toward identifying variables that may protect children against sleep problems otherwise associated with ethnic minority status and economic adversity, support coping was examined as a moderator. Participants were 235 children (113 boys, 122 girls; M age = 11.33 years, SD = 8.03 months), 64% European American and 36% African American. Children's sleep duration (minutes) and continuity (efficiency) were assessed through actigraphs worn for 1 week. Mothers reported on the family's monetary resources (income-to-needs ratio) and children reported on their support coping strategies. For children from lower income homes and African Americans, a higher level of support coping was a protective factor against fewer sleep minutes and reduced sleep efficiency, otherwise associated with economic adversity. Children from more economically advantaged homes had good sleep parameters regardless of their coping. The results build on the existing small body of work by demonstrating that children's support coping strategies have a protective role against sleep problems otherwise associated with ethnic minority status and economic adversity and present potential targets for intervention that may help reduce health disparities in an important health domain.

Resilience of the immune system in healthy young students to 30-hour sleep deprivation with psychological stress.

OBJECTIVE: Young adults often encounter sleep deprivation and stressful events. Both have been separately reported to modulate immunity, and occasionally they occur simultaneously. We assessed the combined effects of these conditions on immune competence in healthy students. METHODS: Twenty-three participants (mean age 24 years; SD 1.86; 14 females) were exposed to 30 h of sleep deprivation during which they conducted physiological, social and cognitive tasks. The control group consisted of 18 participants (mean age 23.67 years; SD 1.46; 11 females). All participants underwent cognitive and psychological evaluations at 10:00 AM, followed by blood and saliva collection, 3 days before sleep deprivation induction and on the morning following it. Immune/endocrine measures included blood counts of lymphocytes, granulocytes, monocytes and natural killer (NK) cells; levels of several cell surface markers; NK cytotoxicity; plasma levels of interleukin (IL)-6, IL-10, dehydroepiandrosterone and neuropeptide Y, and plasma and salivary cortisol levels. RESULTS: Although the experimental protocol significantly elevated state anxiety and psychological dissociation levels, no effects were evident in any of the immunological/endocrine indices. In contrast, expected sex differences in immune measures were found, including significantly higher NK cytotoxicity and monocyte counts in males, validating the integrity of the measurements. CONCLUSIONS: The findings suggest resilience of the immune system to a combined sleep deprivation and stressful exposure in young adults, while previous studies reported immune perturbations following either of these conditions separately. These apparent contradictions might reflect differences in the study design or in the methodology used for immunological assessments, including the time of sample collection, the combination of sleep deprivation with stress and our in vivo assessment of cytokine levels.

Prevalence of habitual snoring and its correlates in young children across the Asia Pacific.

AIMS: To evaluate: (i) the prevalence of habitual snoring (HS) in a large sample of children aged from birth to 36 months in 14 countries across Asia Pacific; and (ii) the different correlates associated with HS in Caucasians, Chinese and non-Chinese, non-Caucasian Asians. METHODS: This was a multi-centre, cross-sectional survey conducted across Asia Pacific. Parents/caregivers of 23,481 infants and toddlers completed an expanded version of the Brief Infant Sleep Questionnaire. We defined HS as snoring more than three nights per week. RESULTS: Chinese and non-Caucasian non-Chinese (NCNC) children had a lower prevalence of HS across the age range from birth to 3 years than their Caucasian counterparts (6.2% and 5.1% vs. 11%, P < 0.01). Boys had a higher prevalence of HS compared to girls (χ(2) = 98.5, P < 0.0001). History of prematurity (OR = 1.37-1.56, CI (1.1-2.17), P < 0.01) and gender (OR = 1.53-1.54, CI (1.26-1.85), P < 0.0001) were found to be significant predictors for HS. Current breastfeeding (OR = 0.69, CI (0.54-0.88), P < 0.005) and greater parental age (OR = 0.86, CI (0.78-0.96), P < 0.01) were protective against HS among NCNC children. HS was less prevalent in younger Chinese subjects (OR = 0.88, CI (0.84-0.93), P < 0.0001). In Caucasians, parents' education (OR = 0.78, CI (0.67-0.91), P < 0.005) and their not sleeping in the same room as their child (OR = 0.62, CI (0.45-0.86), P < 0.005) were negatively associated with parental report of HS. CONCLUSIONS: Prevalence of HS shows racial differences among countries across Asia Pacific. Future studies should assess craniofacial structure and body fat distribution as contributory factors for this differential prevalence.

Nighttime fears and fantasy-reality differentiation in preschool children.

Nighttime fears are very common in preschool years. During these years, children's fantasy-reality differentiation undergoes significant development. Our study was aimed at exploring the links between nighttime fears and fantasy-reality differentiation in preschool children. Eighty children (aged: 4-6 years) suffering from severe nighttime fears were compared with 32 non-fearful controls. Fears were assessed using child and parental reports. Children viewed images depicting fantastic or real entities and situations, and were asked to report whether these were imaginary or could occur in real life. The results revealed that children with nighttime fears demonstrated more fantasy-reality confusion compared to their controls. These differences in fantasy-reality differentiation were more pronounced in younger children. Additional significant associations were found between fantasy-reality differentiation and age and specific characteristics of the stimuli. These preliminary findings, suggesting a developmental delay in fantasy-reality differentiation in children with nighttime fears, have significant theoretical and clinical implications.

Assessment of brief interventions for nighttime fears in preschool children.

UNLABELLED: Nighttime fears (NF) and sleep problems continue to be major problems in clinical services. The aim was to assess the effects of two brief interventions on NF, and related sleep problems and parental fear-reducing behaviors in children. One hundred and four children aged 4-6 years with significant NF were randomly assigned into two intervention groups: the Huggy-Puppy intervention (HPI), which is based on providing children a puppy doll with a request to take care of the doll, and a revised version (HPI-r) which is based on providing the same doll with a cover story that the doll will serve as a protector. At baseline, the domains of NF, behavior problems, and sleep disruptions were assessed. Data were collected from parents and children using objective and subjective measures. The effects of the interventions were assessed by comparing four time points: baseline, first week of intervention, 1 month, and 6 months after initial intervention time. A waiting list comparison group (WL) was used as spontaneous recovery comparison group. Both interventions significantly reduced NF with similar impact. The improvement after 1 month was significantly higher than in the WL group. Furthermore, both interventions significantly reduced parental fear management behaviors and children's sleep problems. Finally, the reduction in NF and parental fear management strategies were maintained 6 months post-treatment. CONCLUSIONS: Relatively simple and cost-effective doll interventions can reduce NF and their associated sleep problems. Further research is needed to implement these interventions for other anxiety disorders in childhood.

Infant and toddler sleep in Australia and New Zealand.

AIMS: To characterize sleep patterns and sleep problems in a large sample of young children (birth to 36 months) in Australia (AU) and New Zealand (NZ). METHODS: Parents and caregivers of 2154 infants and toddlers in AU and NZ completed an expanded version of the Brief Infant Sleep Questionnaire. RESULTS: Overall, young children in AU and NZ go to bed relatively early (19:35), awaken on average 1.08 times per night for an average of 23 min, have a low likelihood of bed-sharing with parents (7.2%) and obtain an average of 13.24 h total sleep. However, a significant percentage of parents perceive that their child has a sleep problem (30.69%). Sleep patterns in these children demonstrate clear developmental changes, including a decrease in daytime sleep and total sleep time, as well as consolidation of sleep during the night (decrease in night wakings and nocturnal wakefulness). Parents in AU and NZ are also highly likely to encourage independence and self-soothing, especially after the age of 3 months. CONCLUSIONS: These findings provide parents and professionals reference data for assessing sleep in young children, as well as common parenting practices related to sleep behaviours.

Effect of current breastfeeding on sleep patterns in infants from Asia-Pacific region.

AIM: The aim of this study was to assess the relationship between breastfeeding and sleep patterns in infants from Asia-Pacific region. METHODS: Parents of 10 321 infants (0-11 months) from Australia, China, Hong Kong, India, Indonesia, Korea, Japan, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand and Vietnam completed an expanded version of the Brief Infant Sleep Questionnaire. RESULTS: Overall, 4714 (45.72%) were currently being breastfed; 61.3% of those between 0 and 5 months and 36.6% of those between 6 and 11 months. Currently breastfed infants, when compared with not currently breastfed infants, had a significant increase in the number and duration of night-time wakings and less consolidated sleep. Interestingly, currently breastfed infants less than 6 months also showed longer duration of daytime sleep and obtained more sleep overall. Of note, of those who were currently breastfed, those infants who were nursed back to sleep during night, woke up more often at night (2.41 vs. 1.67 times) and had shorter continuous night-time sleep period (5.58 vs. 6.88 h; P < 0.001). There was no significant difference between breastfeeding and non-breastfeeding infants in the number of night wakings, when the nursing to sleep variable was controlled for in the analysis of variance. CONCLUSION: Breastfeeding is associated with reduced sleep consolidation in infants. This relationship, however, may be moderated by parenting practices of nursing to sleep and back to sleep during the night. Thus, parents of infants with night waking problems should be encouraged to limit the association between nursing and falling to sleep, to improve sleep while maintaining breastfeeding.

Infant sleep and paternal involvement in infant caregiving during the first 6 months of life.

OBJECTIVES: The goals of this study were to assess: (a) the involvement of fathers and mothers in overall and nighttime infant caregiving; (b) the links between paternal involvement in infant care and infant sleep patterns during the first 6 months. METHODS: Fifty-six couples recruited during their first pregnancy, participated in the study. After delivery (1 and 6 months), both parents completed a questionnaire assessing the involvement of fathers relative to mothers in infant caregiving. Infant sleep was assessed using actigraphy and sleep diaries. RESULTS: Mothers were significantly more involved than fathers in daytime and nighttime caregiving. A higher involvement of fathers in overall infant care predicted and was associated with fewer infant night-wakings and with shorter total sleep time after controlling for breastfeeding. CONCLUSIONS: The findings highlight the importance of including fathers in developmental sleep research. Future studies should explore mechanisms underlying the relations between paternal involvement and infant sleep.