Children's Sleep and Externalizing Problems: A Day-to-day Multilevel Modeling Approach.

BACKGROUND: Sleep problems and externalizing problems tend to be positively associated, but the direction of this association is unclear. METHOD: Day-to-day associations between sleep and behavior were examined in children (N = 22) ages 3-8 with clinical levels of externalizing problems. These children were enrolled in Parent Management Training and behavioral sleep intervention. During assessments before and after treatment, children wore actigraphs for seven days and parents concurrently completed sleep diaries and daily tallies of noncompliance, aggression, and tantrums. Multilevel modeling was used to account for the nested structure of the data, at the day-to-day level (level 1), within assessment points (level 2), and within children (level 3). RESULTS: Late sleep timing and fragmentation were predictive of next-day noncompliance and tantrums, respectively. There were fewer associations for a given day's behavior predicting that night's sleep, although children who showed more aggression and noncompliance at baseline tended to have later bedtimes and sleep onset times compared to other children.

Screening for Problematic Sleep in a Diverse Sample of Infants.

OBJECTIVE: To examine screening strategies for identifying problematic sleep in a diverse sample of infants. METHODS: Parents of infants (5-19 months; N = 3,271) presenting for a primary care visit responded to five screening items and the Infant Sleep Questionnaire (ISQ), a validated measure of problematic infant sleep. If parents responded affirmatively to any screening item, primary care providers received a prompt to evaluate. For each of the screening questions, we examined differences in item endorsement and criterion related validity with the ISQ. Using conceptual composites of night waking and sleep difficulty, prevalence, criterion-related validity, and concurrent demographic correlates were analyzed. RESULTS: Infants were primarily of Black race (50.1%) or Hispanic ethnicity (31.7%), with the majority (63.3%) living in economically distressed communities. Rates of problematic sleep ranged from 7.4%, for a single item assessing parental perception of an infant having a sleep problem, to 74.0%, for a single item assessing night wakings requiring adult intervention. Items assessing sleep difficulty had high (95.0-97.8%) agreement with the ISQ in identifying infants without problematic sleep, but low agreement (24.9-34.0%) in identifying those with problematic sleep. The opposite was true for items assessing night waking, which identified 91.0-94.6% of those with sleep problems but only 31.8-46.9% of those without. CONCLUSIONS: Screening strategies for identifying problematic infant sleep yielded highly variable prevalence rates and associated factors, depending on whether the strategy emphasized parent-perceived sleep difficulty or night wakings. The strategy that is most appropriate will depend on the system's goals.

The Family Context of Toddler Sleep: Routines, Sleep Environment, and Emotional Security Induction in the Hour before Bedtime.

Family processes during the pre-bedtime period likely have a crucial influence on toddler sleep, but relatively little previous research has focused on family process in this context. The current study examined several aspects of family process during the pre-bedtime period, including the use of bedtime routines, the qualities of the child's home sleep environment, and the promotion of child emotional security, in families of 30-month-old toddlers (N= 546; 265 female) who were part of a multi-site longitudinal study of toddler development. These characteristics were quantified using a combination of parent- and observer-reports and examined in association with child sleep using correlation and multiple regression. Child sleep was assessed using actigraphy to measure sleep duration, timing, variability, activity, and latency. Bedtime routines were examined using parents' daily records. Home sleep environment and emotional security induction were quantified based on observer ratings and in-home observation notes, respectively. All three measures of pre-bedtime context (i.e., bedtime routine inconsistency, poor quality sleep environments, and emotional security induction) were correlated with various aspects of child sleep (significant correlations:.11-.22). The most robust associations occurred between the pre-bedtime context measures and sleep timing (i.e., the timing of the child's sleep schedule) and variability (i.e., night to night variability in sleep timing and duration). Pre-bedtime variables, including bedtime routine consistency, home sleep environment quality, and positive emotional security induction, also mediated the association between family socioeconomic status and child sleep. Our findings underscore the value of considering family context when examining individual differences in child sleep.

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.

Parents Influence the Visual Learning Environment Through Children's Manual Actions.

The present research studied children in the second year of life (N = 29, Mage  = 21.14 months, SD = 2.64 months) using experimental manipulations within and between subjects to show that responsive parental influence helps children have more frequent sustained object holds with fewer switches between objects compared to when parents are either not involved or over-involved. Regardless of parental involvement, sustained holds were visually rich, based on the size, centeredness, and dominance of the held object relative to other objects. These findings are important because they suggest not only that the child's body creates visually rich scenes across play contexts but also that a responsive parent can increase the frequency of these visually rich and informative moments.

Maternal Executive Function and Sleep Interact in the Prediction of Negative Parenting.

Objective/Background: Poorer executive function (EF) has been implicated in the etiology of negative parenting (e.g., harsh, reactive, intrusive). EF may be affected by good or poor quality sleep, and thus sleep may be involved in negative parenting. In the current exploratory study, we investigated the additive and interactive effects of maternal EF and sleep indicators in the statistical prediction of negative parenting. Patients/Methods: A sample of 241 mothers of 2.5-year-olds (51% girls) completed questionnaires, wore wrist actigraphs for one week, and completed several EF tasks during a laboratory visit. Results/Conclusions: We found that sleep activity (e.g., nighttime waking and movements) interacted with EF in predicting negative parenting practices, such that poorer EF was linked with more negative parenting only in the context of higher levels of night waking. Sleep duration also interacted with EF, such that EF and parenting were no longer associated when sleep durations were short. The findings have implications for incorporating sleep into our understanding of maternal cognitive self-regulation and harsh parenting during early childhood development.

Dysregulation in children: Origins and implications from age 5 to age 28.

Research shows that childhood dysregulation is associated with later psychiatric disorders. It does not yet resolve discrepancies in the operationalization of dysregulation. It is also far from settled on the origins and implications of individual differences in dysregulation. This study tested several operational definitions of dysregulation using Achenbach attention, anxious/depressed, and aggression subscales. Individual growth curves of dysregulation were computed, and predictors of growth differences were considered. The study also compared the predictive utility of the dysregulation indexes to standard externalizing and internalizing indexes. Dysregulation was indexed annually for 24 years in a community sample (n = 585). Hierarchical linear models considered changes in dysregulation in relation to possible influences from parenting, family stress, child temperament, language, and peer relations. In a test of the meaning of dysregulation, it was related to functional and psychiatric outcomes in adulthood. Dysregulation predictions were further compared to those of the more standard internalizing and externalizing indexes. Growth curve analyses showed strong stability of dysregulation. Initial levels of dysregulation were predicted by temperamental resistance to control, and change in dysregulation was predicted by poor language ability and peer relations. Dysregulation and externalizing problems were associated with negative adult outcomes to a similar extent.

Assessment and management of anxiety and depression in a pediatric high-risk asthma clinic.

OBJECTIVE: The aims of this study were to determine the prevalence of positive mental health (MH) screens in a pediatric high-risk asthma (HRA) clinic population, and to determine the success rate of engagement in MH services before and after adding a clinical psychologist to our multidisciplinary clinic. HYPOTHESIS: We hypothesized that the HRA population would have a higher prevalence of anxiety/depression symptoms than that previously reported for the general pediatric asthma population. We anticipated that the presence of an embedded psychologist in HRA clinic would facilitate successful connection to MH services. METHODS: Pediatric patients in the HRA clinic were prospectively screened for anxiety and depression using validated screening instruments. Positive scores were referred for MH services. Time to MH service engagement was recorded before and after the addition of a clinical psychologist. RESULTS: A total of 186 patients were screened; 60% had a positive MH screen. Female sex was associated with higher median scores on both screening tools and higher likelihood of engagement in MH services. After addition of a clinical psychologist, new engagement in MH services increased (20% vs. 80%, p < 0.0001), and median time to engagement decreased (14.5 vs. 0.0 months, p = 0.003). CONCLUSION: There is a high prevalence of anxiety and depression in this pediatric HRA population. Success of engagement in MH services improved after a clinical psychologist joined our multidisciplinary team, suggesting access to care as a primary barrier to engagement.

Concurrent and longitudinal associations among insomnia symptoms, internalizing problems, and chronic pain in youth.

OBJECTIVE: Although insomnia symptoms and chronic pain are associated, less is known about the temporal nature of the associations between these variables or the impact of internalizing symptoms on the associations. Concurrent and longitudinal associations were examined among insomnia symptoms, internalizing symptoms, and pain in youth with chronic pain in this retrospective analysis of clinical records. We hypothesized the following: (a) pain, insomnia symptoms, and internalizing symptoms would be significantly interrelated at all waves, (b) insomnia symptoms would more strongly predict future pain than the reverse, and (c) internalizing symptoms would mediate the longitudinal association between insomnia symptoms and pain. METHOD: Youth (N = 132; age M = 15.34 years, SD = 1.86 years) were assessed at their initial and two subsequent appointments (time between appointments M = 6.48 months, SD = 4.43 months). At each appointment, youth reported their pain severity, insomnia symptoms, and internalizing symptoms. Confirmatory factor analyses (CFAs) and cross-lagged panel models using structural equation modeling were conducted. CFAs and the cross-lagged panel model with pain and insomnia symptoms as latent constructs converged. RESULTS: Pain and insomnia symptoms were positively correlated within each wave. We found bidirectional longitudinal associations between insomnia symptoms and pain. CONCLUSIONS: Overall, these data demonstrate a bidirectional relationship between insomnia symptoms and pain, as well as weak support for internalizing symptoms mediating the association between pain and insomnia symptoms. Treatment of youth with chronic pain should prioritize concurrent or early treatment of comorbid insomnia symptoms to maximize response to pain treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A 1-year longitudinal study of the stress, sleep, and parenting of mothers of toddlers.

OBJECTIVES: The present study, building on cross-sectional research showing links between mothers' sleep, stress, and parenting, used a longitudinal design to consider (1) the temporal direction of links between mothers' sleep and stress, (2) whether mother sleep deficits predict change in parenting across time, and (3) whether mother sleep deficits mediate the inverse association between stress and positive parenting. DESIGN: The study used repeated measures of stress, mother sleep, and positive parenting at toddler ages 30, 36, and 42 months. SETTING: Data were collected at 2 sites, one in the Midwest and one in the East. PARTICIPANTS: Four hundred thirteen mother-toddler pairs were followed. Mothers were mostly married, college educated, and middle class, but there was also considerable variability between families. MEASUREMENTS: Stress was measured via parenting hassles, CHAOS, and role overload scales. Mother sleep was measured via actigraphy. Positive parenting was observed during the bedtime routine and rated using the HOME scale and other items. RESULTS: Mother stress and sleep were inextricably linked across toddlerhood, and worse sleep was predictive of less observed positive parenting, even when controlling for prior levels of stress and parenting. CONCLUSIONS: Improving mothers' sleep may be important in efforts to improve their parenting.

Sleep and Negative Affect Across Toddlerhood in the Context of Stress.

Negative affect is associated with both high stress and poor sleep, but questions remain about the direction of these associations across time and interactions between stress and sleep, especially in early childhood. The present study examined sleep deficits, family stress, and observed negative affect in a sample of toddlers at 30, 36, and 42 months (N = 504). Negative affect was observed during a parent-child free play task. Sleep was measured via actigraphy. Stress was measured using a cumulative risk index of socioeconomic status, single parent status, household chaos, role overload, parenting hassles, social support, and stressful events. Findings showed few associations between sleep and negative affect, except for toddlers experiencing high levels of family stress. Toddlers experiencing both high stress and poor sleep demonstrated the highest levels of negative affect in the lab at 30 months. Adequate sleep may serve as a protective factor for children in high-stress families.

The physical home environment and sleep: What matters most for sleep in early childhood.

The physical home environment is thought to play a crucial role in facilitating healthy sleep in young children. However, relatively little is known about how various features of the physical home environment are associated with sleep in early childhood, and some of the recommendations clinicians make for improving child sleep environments are based on limited research evidence. The present study examined how observer and parent descriptions of the child's physical home environment were associated with child sleep, measured using actigraphy and parent's reports, across a year in early childhood. The study used a machine learning approach (elastic net regression) to specify which aspects of the physical home environment were most important for predicting five aspects of child sleep, sleep duration, sleep variability, sleep timing, sleep activity, and latency to fall asleep. The study included 546 toddlers (265 females) recruited at 30 months of age and reassessed at 36 and 42 months of age. Poorer quality physical home environments were associated with later sleep schedules, more variable sleep schedules, shorter sleep durations, and more parent-reported sleep problems in young children. The most important environmental predictors of sleep were room sharing with an adult, bed sharing, and quality of both the child's sleep space and the wider home environment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Mothers' sleep deficits and cognitive performance: Moderation by stress and age.

There are well-known associations between stress, poor sleep, and cognitive deficits, but little is known about their interactive effects, which the present study explored in a sample of mothers of toddlers. Since certain types of cognitive decline start during the 20s and continue into later ages, we also explored whether mothers' age interacted with stress and sleep in the prediction of cognitive functioning. We hypothesized that poorer sleep [measured using one week of 24-hour wrist actigraphy data] and having more chronic stressors [e.g., life events, household chaos, work/family role conflict] would be linked with poorer cognitive performance [both executive function and standardized cognitive ability tasks], and that the interactive combination of poorer sleep and more stressors would account for the effect. We also explored whether this process operated differently for younger versus older women. In a socioeconomically and geographically diverse community sample of 227 women with toddler-age children [age, M = 32.73 yrs, SD = 5.15 yrs], poorer cognitive performance was predicted by greater activity during the sleep period, shorter sleep duration, and lower night-to-night consistency in sleep; it was not associated with higher levels of stress. The interactive effects hypothesis was supported for sleep activity [fragmented sleep] and sleep timing [when mothers went to bed]. The combination of more exposure to stressors and frequent night waking was particularly deleterious for older women's performance. For younger women, going to bed late was associated with poorer performance if they were experiencing high levels of stress; for those experiencing low levels of stress, going to bed late was associated with better performance.

Screen use before bedtime: Consequences for nighttime sleep in young children.

There is increasing interest in the relation between screen use and sleep problems in early childhood. In a sample of 30-month-old children, this study used observational measures of screen use during the hour or so leading up to bedtime, parent reports of screen use during the child's bedtime routine, and actigraphic measures of toddler sleep to complement parent-reported sleep problems. Whether screen use was observed during the pre-bedtime period or was reported by the parents as part of the nightly bedtime routine, greater screen use in either context was associated with more parent-reported sleep problems. Additionally, more frequent parent-reported screen use during the bedtime routine was also associated with actigraphic measures of later sleep, shorter sleep, and more night-to-night variability in duration and timing of sleep. These associations suggest the negative consequences of screen use for children's sleep extend both to aspects of sleep reported by parents (e.g., bedtime resistance, signaled awakenings) and to aspects measured by actigraphy (e.g., shorter and more variable sleep).

Sleep and self-regulation in early childhood.

What is the role of sleep in children's behavioral, emotional, and cognitive regulation? This chapter considers theoretical and conceptual links between sleep and self-regulation, with special attention to sleep and self-regulation in early childhood. We selectively review the growing body of research on associations between sleep and self-regulation, mentioning some methodological issues. We also consider how child characteristics and sociocontextual factors may interact with sleep in the development of self-regulation in early childhood. We provide some relevant empirical examples from our own research.

Sustained attention across toddlerhood: The roles of language and sleep.

The present study examined individual differences in the development of sustained attention across toddlerhood, as well as how these individual differences related to the development of language and sleep. Toddlers (N = 314; 54% male) were assessed at 30, 36, and 42 months using multiple measures of attention, a standardized language assessment, and actigraphic measures of sleep. Toddlers were 80% White. Family socioeconomic status (SES) was calculated using the Hollingshead Four Factor Index and ranged from 13 to 66 (M = 47.59, SD = 14.13). Aims were (a) to examine associations between measures of attention across situations, informants, and time; (b) to consider the independent and interactive effects of language and sleep on attention; and (c) to test potential bidirectional associations between sleep and attention. Findings showed attention measures were stable across time but were only weakly linked with each other at 42 months. Attention was consistently linked with language. More variable sleep and longer naps were associated with less growth in sustained attention across time. Nighttime sleep duration interacted with language in that sleep duration was positively associated with attention scores among toddlers with less advanced language, even when SES was controlled. The findings describe an understudied aspect of how sustained attention develops, involving the main effect of consistent sleep schedules and the interaction effect of amount of sleep and child language development. These findings are relevant to understanding early childhood risk for developing attention problems and to exploring a potential prevention target in family sleep practices. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Pediatric behavioral sleep medicine in the era of telemedicine: psychology trainee perspectives.

The worldwide coronavirus pandemic in 2020 radically changed the landscape of psychology service provision and training, with rapid rollouts of telemedicine to promote safe access to care. In this perspective article, we share the experiences of 4 psychology trainees, all of whom worked as psychology interns or postdoctoral fellows in pediatric behavioral sleep medicine during the pandemic. With restricted in-person visits and upheaval of children's normative sleep and school schedules, we directly observed growth in both need for psychological care and opportunity to provide this care remotely. Here, we summarize the unique challenges and learning opportunities we faced when trying to learn and implement evidence-based assessment and treatment of child and adolescent sleep difficulties during the pandemic. CITATION: McQuillan ME, Anderson A, Russo KD, Truss A, Honaker SM, Walsh KL. Pediatric behavioral sleep medicine in the era of telemedicine: psychology trainee perspectives. J Clin Sleep Med. 2021;17(9):1965-1967.

Heterotypic continuity of inhibitory control in early childhood: Evidence from four widely used measures.

Inhibitory control has been widely studied in association with social and academic adjustment. However, prior studies have generally overlooked the potential heterotypic continuity of inhibitory control and how this could affect assessment and understanding of its development. In the present study, we systematically considered heterotypic continuity in four well-established measures of inhibitory control, testing two competing hypotheses: (a) the manifestation of inhibitory control coheres within and across time in consistent, relatively simple ways, consistent with homotypic continuity. Alternatively, (b) with developmental growth, inhibitory control manifests in more complex ways with changes across development, consistent with heterotypic continuity. We also explored differences in inhibitory control as a function of the child's sex, language ability, and the family's socioeconomic status. Children (N = 513) were studied longitudinally at 30, 36, and 42 months of age. Changes in the patterns of associations within and among inhibitory control measures across ages suggest that the measures' meanings change with age, the construct manifests differently across development, and, therefore, that the construct shows heterotypic continuity. We argue that the heterotypic continuity of inhibitory control motivates the use of different combinations of inhibitory control indexes at different points in development in future research to improve validity. Confirmatory factors and growth curves also suggest that individual differences in inhibitory control endure, with convergence among inhibitory control measures by 36 months of age. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Measuring sleep in young children and their mothers: Identifying actigraphic sleep composites.

The present study considered multiple aspects of sleep in a community sample of young children (at ages 30, 36, and 42 months) and their mothers, using both diaries and actigraphy. Through principal components analysis, 17 of 20 commonly used actigraphy variables were reduced to four main components whose variables formed composites of: Activity, night-to-night Variability, Timing, and Duration. Sleep latency and daytime sleep variables remained separate from the composites. The same components were identified at each age, and for both children and mothers. Furthermore, the sleep composites derived from the components showed greater cross-age stability than individual actigraphy variables. Finally, child and mother sleep composites were related concurrently and longitudinally. These findings demonstrate a systematic and efficient way of summarizing child and mother sleep with actigraphy variables.