Racial/ethnic sleep disparities in US school-aged children and adolescents: a review of the literature

Sex and racial/ethnic differences in sleep quality and its relationship with body weight status among US college students

Objective: To examine sex and racial/ethnic differences in sleep quality and the association between sleep quality and body weight status among US college students. Participants: A nationally representative sample (N = 324,767) of college students from 2011 to 2015. Methods: A secondary data analysis of cross-sectional data. Results: Women showed poorer sleep quality (nights per week getting enough sleep to feel rested) than men (4.00 versus 4.34 days; p < .001). In both men and women, compared with non-Hispanic whites, racial/ethnic minorities showed lower sleep quality (p < .001). Compared with normal weight participants, overweight participants had poorer sleep quality (p = .007) among men, and both overweight (p = .004) and obese participants (p < .001) had lower sleep quality among women. Conclusions: Understanding sex and racial/ethnic sleep differences and the association between sleep and body weight status is important for colleges to promote college students' healthy sleep.

Sleep Problems and Drinking Frequency among Urban Multiracial and Monoracial Adolescents: Role of Discrimination Experiences and Negative Mood

Mounting evidence suggests that multiracial adolescents may be at greater risk than their monoracial peers for both sleep problems and alcohol use. However, mechanisms underlying these uniquely-heightened risky health behaviors among multiracial adolescents remain a gap in the literature. This cross-sectional study examined a risk pathway involving discrimination experiences and negative mood underlying racial disparities in concurrent sleep problems and drinking frequency. Students at an urban, socioeconomically-disadvantaged high school (N = 414; grades 9-11, Mage = 16.00 [SD = 1.08]; 57% female; 17% multiracial, 41% Black, 22% White, 18% Asian, 2% Other; 12% Hispanic/Latinx) completed a survey. Path analysis demonstrated that associations of multiracial status with sleep problems (insomnia symptom severity and insufficient weekday sleep duration), but not drinking frequencies (past-year drinking or past-2-week binge-drinking frequencies), were explained by discrimination experiences and, in turn, negative mood. In ancillary analysis excluding White students, the serial indirect risk pathway was significant for both insomnia symptom severity and past-year drinking frequency outcomes. Discrimination experiences and negative mood may function as intermediate factors contributing to racial disparities in adolescent sleep problems, although longitudinal replication is needed.

Disparities in Sleep Health and Potential Intervention Models: A Focused Review

Disparities in sleep health are important but underrecognized contributors to health disparities. Understanding the factors contributing to sleep heath disparities and developing effective interventions are critical to improving all aspects of heath. Sleep heath disparities are impacted by socioeconomic status, racism, discrimination, neighborhood segregation, geography, social patterns, and access to health care as well as by cultural beliefs, necessitating a cultural appropriateness component in any intervention devised for reducing sleep health disparities. Pediatric sleep disparities require innovative and urgent intervention to establish a foundation of lifelong healthy sleep. Tapping the vast potential of technology in improving sleep health access may be an underutilized tool to reduce sleep heath disparities. Identifying, implementing, replicating, and disseminating successful interventions to address sleep disparities have the potential to reduce overall disparities in health and quality of life.

Sleep, psychopathology and cultural diversity

Research on ethnic/racial disparities in sleep in the United States finds minorities to have shorter self-reported and actigraphy-recorded sleep duration and poorer sleep quality. Disparities in mental health mirror disparities in sleep with ethnic/racial minorities reporting higher prevalence and more severe struggles. This review focuses on recent research in sleep and mental health disparities and considers ethnic/racial discrimination as an important third variable that may link these two domains of disparities research. For example, research has found discrimination to mediate ethnic/racial disparities in sleep; at the same time, sleep has been observed to mediate the link between discrimination and mental health. The review concludes with the importance of considering ethnicity/race and accompanying sociodemographic, environmental, and behavioral influences on sleep and mental health research.

Gender Discrimination, Perceived School Unfairness, Depressive Symptoms, and Sleep Duration Among Middle School Girls

The current study examines how gender discrimination by adults in school is linked with depressive symptoms and sleep duration over time in middle school. The main goal is to test one psychological mechanism that can account for such associations: perceived school unfairness. Relying on a racially-ethnically diverse sample of girls (N = 2,718, M_age  = 13.01, SD_age  = 0.39) from 26 middle schools, multilevel mediation analyses revealed that girls who experienced school-based gender discrimination by an adult in seventh grade reported higher levels of perceived school unfairness in eighth grade. Moreover, perceived unfairness, in turn, was associated with more depressive symptoms and shorter sleep durations by eighth grade. Implications of changes in adolescent girls' sleep and mood related to their experiences of gender discrimination are discussed.

Frequency of physical inactivity and insufficient sleep, and their mixed effects on academic achievement in ethnic minority students: A matched case-control study in a dental school

BACKGROUND

Ethnic minorities are underrepresented in health sciences programs in various nations. Furthermore, there is no known research studying the occurrence of physical inactivity (PI) and insufficient sleep (IS), and their effects on academic achievement (AA) in ethnic minority students (EMS) in higher education.

OBJECTIVE

The objective of this study is to explore the occurrence of PI and IS, and their independent and mixed effects on AA in EMS of a dental school.

MATERIALS AND METHODS

Thirty EMS and sixty non-EMSs were matched (1:2) in this case-control study. It was utilized as an administrative dataset that stores register related to the students. Moreover, the grade point average was considered an indicator of AA. Logistic regressions models were run, expressed in odds ratios, complemented by confidence intervals (CIs) of 95%.

RESULTS

A total of 73% and 60% EMS were PI and slept insufficiently, respectively. The groups presented statistically significant differences (P < 0.0001) in physical activity, sleep, and AA, with inferior values for EMS. All unadjusted models showed that PS, IS, and low AA were strongly associated with EMS, demonstrating their independent effect. After controlling for PI and IS, the multivariate model for AA and EMS increased odds by 6.5 times (95%CI: 1.8-23;), indicating that EMS is strongly associated with low AA. Besides, PI and IS were also statistically significant higher (< 0.0001) in the model, demonstrating their mixed effect.

CONCLUSIONS

This study found a higher occurrence of PI and IS in EMS. Besides, independent and mixed effects of these variables on low AA in EMS were very significant.

Demographic and Socioeconomic Influences on Sleep Patterns among Adolescent Students

Although proper sleep is an important topic in adolescent health, little is known about the sleep patterns of adolescents from a longitudinal and non-Western perspective. To fill this gap, the present research conducted a longitudinal study of the impact of demographic and socioeconomic factors on sleep patterns among Korean adolescent students. The relationship could positively or negatively affect sleep. Therefore, it is important to understand which demographic and socioeconomic factors are related to sleep patterns. This study used nationally representative panel data from the Korean Children and Youth Panel Survey. A series of descriptive analyses were conducted to provide overall characteristics of the sample. Furthermore, mixed effect regression analysis techniques were employed to test the relationship between demographic and socioeconomic factors and sleep patterns. Paternal employment status was associated with adolescent sleep patterns, while maternal employment status was not. Adolescents with both parents working compared to adolescents with one parent or none working showed different sleep patterns on weekdays but not on weekends. Both parents possessing college degrees, household income, living in an urban area, and family type were associated with adolescent sleep pattern indicators to varying degrees. Some of these associations varied according to adolescent sex. This study provides insight into the impact of demographic and socioeconomic factors on weekend and weekday sleep patterns among adolescent students by sex. These findings provide information for the promotion of healthy sleep in adolescents by addressing demographic and socioeconomic factors.

Resilience factors, race/ethnicity and sleep disturbance among diverse older females with hypertension

BACKGROUND

This study examined the relationships between resilience and sleep disturbance in a diverse sample of older women with a history of hypertension and whether this relationship is moderated by individuals' race/ethnicity.

METHODS

Sample includes 700 females from a community-based study in Brooklyn, New York with a mean age of 60.7 years (SD=6.52). Of the participants, 28.1% were born in the U.S.; 71% were African-descent, 17.4% were European and 11.6% were Hispanics descents. Data were gathered on demographics and sleep disturbance using the Comprehensive Assessment and Referral Evaluation (CARE) and the Stress Index Scale (SIS). Resilience Factors were assessed with both the Index of Self-Regulation of Emotion (ISE) and religious health beliefs. Chi-Square, Anova, Student t-tests, and multilinear regression analysis were conducted to explore associations between resilience factors and sleep disturbance. Associations between resilience factors and sleep disturbance were examined using stratified multilinear regression analysis in three models by race/ethnicity. Regression models was conducted examining the interaction between resilience factors and stress RESULTS: Resilience factor, ISE emerged as the strongest independent predictor of sleep disturbance [B(SE) = -0.368(0.008); p < .001] for African descents. ISE was not a significant predictor of sleep disturbance among Hispanic participants [B(SE) = -0.218(0.022);p = .052], however interaction effect analysis revealed that stress level moderates significantly the relationship between ISE, and their sleep disturbance [B(SE) = 0.243(0.001);p = .036].

CONCLUSIONS

Results of our study suggest that resilience factors might be a more important protective factor for sleep disturbance among diverse older females.

Does context matter? A multilevel analysis of neighborhood disadvantage and children's sleep health

OBJECTIVES

To determine how demographic, socioeconomic, and neighborhood characteristics are associated with bedtimes among US kindergarteners.

DESIGN

Parents reported bedtimes of their children as well as personal, household, and residential characteristics via interviews in the Early Childhood Longitudinal Study-Kindergarten (ECLS-K) Class of 1998-1999. The ECLS-K links individual households to US Census tracts.

SETTING

A random selection of 1,280 schools and surrounding communities in the US.

PARTICIPANTS

A random selection of 16,936 kindergarteners and their parents.

MEASUREMENTS

The 2 outcomes were regular and latest weekday bedtimes of kindergarteners. Through a series of nested multilevel regression models, these outcomes were regressed on individual- and neighborhood-level variables, including race/ethnicity, sex, family type, household income, mother's educational attainment, neighborhood disorder, and several additional neighborhood characteristics.

RESULTS

Models showed significant (P < .05) bedtime disparities by race/ethnicity, sex, family income, and mother's educational attainment. Additionally, models tended to indicate that kindergarteners from disadvantaged neighborhoods experienced later bedtimes than children from more advantaged areas. Neighborhood characteristics accounted for a portion of racial/ethnic differences, suggesting that bedtime disparities are partly rooted in disparate environmental conditions.

CONCLUSIONS

Reducing disparities in childhood sleep may require programs that target not only children and their parents, but also the communities in which they reside.

Mental health and sleep disparities in an urban college sample: A longitudinal examination of White and Black students

OBJECTIVE

Racial disparities in sleep may be consequential among college students given high rates of dysfunctional sleep among this population. The present study sought to investigate whether disparities in sleep explain existing mental health disparities.

METHOD

Data included secondary analysis of a college risk behaviors and health study (n = 1242, mean age = 18.5). Race was dichotomized as White or Black, excluding all others, with participants completing measures of sleep at baseline and measures of depression and anxiety at follow-up 1 to 2 years later.

RESULTS

Compared to White students, Black students were more likely to report lower rates of depression and anxiety, but poorer sleep outcomes. Mediation analyses revealed that sleep partially mediated (suppressed) the association between race and depressive and anxiety symptoms.

CONCLUSIONS

Results indicate that disparities in sleep may play an important role in the association between race and mental health symptoms among college students. Future health disparity research would benefit from exploring the potentially bidirectional relationship between sleep and mental health symptoms among college students.

Disparities in adolescent sleep health by sex and ethnoracial group

Improving adolescent sleep health is a national priority for ameliorating health and wellbeing (Healthy People 2020), as the majority of adolescents do not get the minimum recommended amount of 8 h of sleep per night. Prior research has identified sex and ethnoracial disparities in adolescent sleep but has been limited by data availability. National studies have collected reported sleep data, while objective sleep data has been available in community samples only. Using new data from adolescents in the Fragile Families and Child Wellbeing Study, a population-based birth cohort study of children born 1998–2000, we are able to characterize sex and ethnoracial disparities in sleep health in the first national sample of actigraphy-assessed sleep health among adolescents. In cross-sectional analyses, we used linear and logistic regression models to assess sex and ethnoracial disparities in weekday sleep duration, timing, and quality measured using actigraphy collected from 738 adolescents at approximately age 15. We identified sex and ethnoracial group differences in weekday and weekend adolescent sleep duration, with larger disparities on weekends than weekdays. Male adolescents had 27-min shorter nightly sleep durations than females on weeknights. Non-Hispanic black adolescents had 32-min shorter nightly sleep durations than non-Hispanic whites on weekdays and 41-min shorter nightly sleep durations on weekends. While sex disparities persisted after accounting for naps, black-white differences were attenuated by napping such that there was no statistically significant black-white disparity in 24-h sleep on either weekdays or weekends. We did not identify disparities in sleep timing or quality. Future research should investigate the pathways through which these disparities arise, including behavioral and contextual mechanisms.

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We examined disparities in objective sleep health among American adolescents.

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We found sex and ethnoracial disparities in weekday and weekend sleep health.

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Males slept less than females and did not compensate by napping more.

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Shorter night sleep of black adolescents vs. white adolescents offset by napping.

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Future research should identify behavioral and contextual origins of disparities.

Racial Disparities in Sleep: Associations With Discrimination Among Ethnic/Racial Minority Adolescents

This study investigates the same-day associations between discrimination and sleep among 350 adolescents ages 13-15 (M = 14.29, SD = 0.65; Asian = 41%, Black = 22%, Latinx = 37%). Assessing sleep duration, sleep onset latency, and wake minutes after sleep onset using wrist actigraphy, Black adolescents slept 35 min less than Asian and 36 min less than Latinx youth. Black adolescents suffered the most wake minutes after sleep onset, followed by Latinx and Asian youth. Latinx youth reported the highest levels of sleep disturbance, whereas Asian youth reported the highest levels of daytime dysfunction. Daily discrimination was associated with lower levels of same-night sleep onset latency, more sleep disturbance, more next-day daytime dysfunction, and higher next-day daytime sleepiness.

Medical Anthropology in Pediatrics: Improving Disparities by Partnering with Families

Cultural health beliefs and practices often affect accuracy of diagnoses, health care delivery, and treatment plan adherence, which can lead to health disparity. However, the effect of these belief systems, and acceptance of health care provider recommendations is not commonly discussed. As the proportion of patients from a variety of ethnic and cultural backgrounds increases, an awareness of these belief systems can help achieve better health outcomes. A provider who is flexible and can understand and possibly integrate traditionally non-Western approaches into their treatment plans may build a stronger bond of trust with their patient, thus building a bridge to better health and well-being. [Pediatr Ann. 2020;49(5):e222-e227.].

Sleep Disturbance Predicts Depression Symptoms in Early Adolescence: Initial Findings From the Adolescent Brain Cognitive Development Study

PURPOSE

The aim of the study was to investigate associations between sleep disturbances and mental health in adolescents.

METHODS

Data are from a national sample of 11,670 U.S. participants (5,594 females, aged 9-10 years, 63.5% white) in the Adolescent Brain Cognitive Development study. Initial longitudinal analyses were conducted for a subset of the sample (n = 4,951). Measures of youth sleep disturbance (disorders of initiating and maintaining sleep, sleep-wake transition disorders, and disorders of excessive somnolence) and "typical" total sleep time (number of hours slept on most nights in the past 6 months) were obtained from the parent-report Sleep Disturbance Scale (Data Release 2.0). Parent-report measures of youth mental health (depression, internalizing, and externalizing behaviors) from the Child Behavior Checklist and typical screen time were included.

RESULTS

At baseline, greater sleep disturbance and shorter total sleep time were associated with greater internalizing, externalizing, and depression scores. After controlling for baseline mental health symptoms, baseline sleep disturbance significantly predicted depression and internalizing and externalizing scores at 1-year follow-up. A significant interaction with sex indicated that the association between disorders of excessive somnolence and depression 1 year later was steeper for girls, compared with boys (p < .001; 95% confidence interval 1.04-3.45).

CONCLUSIONS

Sleep disturbances predicted future mental health, particularly depression in this young sample, highlighting the potential to harness sleep as a tool to mitigate the persistence of depression across early adolescence and potentially prevent an adolescent onset of major depressive disorder.

Sleep health in young children living with socioeconomic adversity

Racially and ethnically diverse young children who live with socioeconomic adversity are at high risk for sleep deficiency, but few behavioral sleep interventions (BSIs) are tailored to their needs. To support the future development of a feasible, acceptable, and culturally relevant sleep intervention, we conducted a community-engaged, mixed-methods study with 40 low-income, racially, and ethnically diverse parents to describe sleep characteristics, sleep habits, and parental sleep knowledge of their 6-36-month-old children and to examine the associations between children's sleep characteristics and sleep habits. This report presents quantitative data from this mixed-methods study. We measured objective (actigraphy) and parent-reported sleep (Brief Infant Sleep Questionnaire) characteristics, sleep habits at bedtime, sleep onset, and during night awakenings, parental sleep knowledge, psychological function (Brief Symptom Inventory), and parenting stress (Parenting Stress Index). Children had low sleep duration (537.2 ± 54.7 nighttime and 111.2 ± 29.8 nap minutes), late bedtimes (22:36 ± 1.5 hr), and high bedtime variability (mean squared successive difference = 3.68 ± 4.31 hr) based on actigraphy. Parental knowledge about sleep recommendations was limited. Sleep habits before bedtime, at sleep onset, and during night awakenings were varied. Sixty-five percent of parents reported co-sleeping. Feeding near bedtime or during the night was associated with later bedtimes, more fragmented sleep, and increased bedtime variability. These findings suggest the need for BSIs to support earlier bedtimes and improve sleep duration and continuity by addressing modifiable behaviors. Tailored BSIs that consider socioecological influences on the development of sleep habits are needed.

Sleep Health: An Opportunity for Public Health to Address Health Equity

The concept of sleep health provides a positive holistic framing of multiple sleep characteristics, including sleep duration, continuity, timing, alertness, and satisfaction. Sleep health promotion is an underrecognized public health opportunity with implications for a wide range of critical health outcomes, including cardiovascular disease, obesity, mental health, and neurodegenerative disease. Using a socioecological framework, we describe interacting domains of individual, social, and contextual influences on sleep health. To the extent that these determinants of sleep health are modifiable, sleep and public health researchers may benefit from taking a multilevel approach for addressing disparities in sleep health. For example, in addition to providing individual-level sleep behavioral recommendations, health promotion interventions need to occur at multiple contextual levels (e.g., family, schools, workplaces, media, and policy). Because sleep health, a key indicator of overall health, is unevenly distributed across the population, we consider improving sleep health a necessary step toward achieving health equity.

Place-Based Diminished Returns of Parental Educational Attainment on School Performance of Non-Hispanic White Youth

BACKGROUND

Youth educational outcomes are a function of a wide range of factors including parental education level. This effect, however, is shown to be smaller for African American, Hispanic, and Asian American youth, a pattern called Marginalization-related Diminished Returns (MDRs). It is, however, unknown if it is race/ethnicity or other conditions associated with race/ethnicity (e.g., poor neighborhood quality) which reduces the marginal returns of parental education for youth.

AIM

To explore whether MDRs are only due to race/ethnicity or if they also remain for non-Hispanic Whites in poor neighborhoods, we compared the association between parental education level and adolescents' school performance based on neighborhood quality in a nationally representative sample of non-Hispanic Whites in the United States.

METHODS

This cross-sectional study used wave 1 of the Add Health study, an ongoing nationally representative cohort, 1994-2019. Participants included 849 non-Hispanic White adolescents between the ages of 12 and 21 years and their parents. The independent variable was parental education level, which was treated as a continuous measure. Age, grade, gender, and parental marital status were the covariates. The dependent variable was school performance (sum of school grades in Math, English, History, and Science). Linear regression models were used for data analysis.

RESULTS

Overall, worse neighborhood quality was associated with worse school performance. Parental education level, however, was not directly associated with youth school performance. We found a statistically significant interaction between parental education level and neighborhood quality suggesting that the strength of the association between parental education and youth school performance weakens as neighborhood quality declines.

CONCLUSION

Parental education level is a more salient determinant of youth educational outcomes in better neighborhoods. The result suggests that MDRs may not be solely due to race/ethnicity but contextual factors that commonly covary with marginalization and poverty. These contextual factors may include segregation, concentration of poverty, and social and physical neighborhood disorder.

What does a good night's sleep mean? Nonlinear relations between sleep and children's cognitive functioning and mental health

STUDY OBJECTIVES

We attempted to identify the duration and quality of sleep associated with the optimal child outcomes in key developmental domains including cognitive functioning, academic performance, and mental health. In doing so, we examined nonlinear associations between the sleep and developmental variables. Based on racial/ethnic disparities in children's sleep, we assessed this variable as a moderator of examined relations.

METHODS

Two hundred eighty-two children participated (Mage = 9.4 years, SD = .72; 52% boys; 65% white/European American, 35% black/African American). Sleep was examined with actigraphy for seven consecutive nights and with self-reports. Actigraphy-based sleep duration (minutes) and quality (efficiency), as well as self-reported sleep quality were derived. Children reported on their mental health and were administered cognitive performance tests. Mothers and teachers reported on children's mental health; teachers also reported on academic functioning. Schools provided academic achievement data.

RESULTS

Sleep duration had an accelerating nonlinear negative association with externalizing behaviors. Nonlinear associations were also detected between both actigraphy-derived and subjective reports of sleep quality and multiple developmental domains including academic functioning and mental health and the best functioning corresponded with the highest levels of sleep quality. Emphasizing the importance of individual differences, several examined associations were moderated by race/ethnicity.

CONCLUSIONS

Sleep duration and quality emerged as nonlinear predictors of multiple domains of child development. Findings illustrate that the benefits of longer and better-quality sleep did not taper off and that assessments of nonlinear relations may enhance understanding of the nature of associations between sleep and child functioning.

Latino adolescents' daily bicultural stress and sleep: Gender and school context moderation

OBJECTIVE

Bicultural stress (i.e., challenge arising from navigating 2 cultural contexts) has significant consequences for Latino youth's health, but researchers have yet to examine the implications of bicultural stress for adolescents' sleep. The goals of this study were to examine whether individual and day-to-day (within-person) differences in bicultural stress were associated with Latino adolescents' sleep onset latency (i.e., time to fall asleep), sleep midpoint (i.e., sleep schedule), sleep duration (i.e., time asleep), and subjective sleep quality.

METHOD

Participants were 209 Latino late adolescents (Mage = 18.10 years; 64.4% female) attending over 90 different high schools who completed 7 daily diary surveys while wearing actigraph wristwatches (N = 1,320 daily observations). Participants also reported sleep problems in a standard survey. Statistical interactions were tested to assess moderation by gender and coethnic school composition.

RESULTS

On average, more bicultural stressors across the week were associated with lower average sleep duration and more sleep problems for male (compared to female) adolescents and youth attending schools with higher (compared to lower) Latino student enrollment. Regarding day-to-day differences, more daily bicultural stressors than usual predicted longer sleep onset latency that night for male adolescents, earlier sleep midpoint that night, and less sleep duration that night for youth attending higher Latino-enrollment schools.

CONCLUSIONS

Latino adolescents' everyday experiences of bicultural stress relate to differences in sleep duration, timing, and quality, with important variation by gender and school context. Results advance existing theory regarding social position factors that differentiate the health implications of bicultural stress for Latino youth. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Sleep patterns and sleep deprivation recorded by actigraphy in 4th-grade and 5th-grade students

OBJECTIVE

This study investigates sleep patterns of fourth- and fifth-grade students using actigraphy.

METHODS

The study included 257 students enrolled in a Southwestern US school district who participated in a novel sleep science curriculum during the Spring 2016-17 and Fall 2017-18 semesters and met the study inclusion criteria. As part of this curriculum, participants underwent 5-7 days of continuous wrist actigraphy and completed an online sleep diary.

RESULTS

Approximately two-thirds of the 9-11-year-old fourth- and fifth-grade students slept less than the minimum 9 h per night recommended by both the American Academy of Sleep Medicine/Sleep Research Society and the National Sleep Foundation. The sleep midpoint time on weekends was about 1 h later than on weekdays. There was a significant effect of age on sleep duration. Compared to 9-year old students, a larger proportion of 10-year old students had a sleep duration less than 8.5 h. Boys had shorter sleep duration than girls, and a larger percentage of boys obtained less than 9 h of sleep compared to girls.

CONCLUSIONS

Insufficient sleep is a highly prevalent condition among 9-11-year-old fourth- and fifth-grade elementary students. Importantly, there is a difference between sleep patterns on weekdays and weekends which may portend greater problems with sleep in adolescence and young adulthood.

Sleep Moderating the Relationship Between Pain and Health Care Use in Youth With Sickle Cell Disease

OBJECTIVES

The purpose of the current study was to investigate the influence of sleep on the relationship between pain and health care use (HCU) in youth with sickle cell disease (SCD). It was hypothesized that poor sleep would be related to higher HCU and would strengthen the relationship between high pain frequency and more HCU among youth with SCD.

MATERIALS AND METHODS

Ninety-six youth with SCD (aged 8 to 17 y) and their guardians were recruited from 3 regional pediatric SCD clinics. Guardians reported on the youth's pain frequency and HCU using the Structured Pain Interview for parents, and youth wore a sleep actigraph for up to 2 weeks to assess sleep duration and sleep efficiency. A series of regression models were calculated with the following outcomes: emergency department visits, hospitalizations, and health care provider contacts.

RESULTS

Inconsistent with hypotheses, poor sleep was not directly related to HCU. Also, higher sleep duration appeared to strengthen the relationship between high pain frequency and more emergency department visits.

CONCLUSIONS

Findings suggest that good sleep may serve as a protective factor for better matching pain to HCU. Results should be interpreted in the context of study limitations. Research is needed to investigate possible mechanisms linking sleep duration to HCU in response to pain and to ascertain if sleep patterns influence the relationship between pain and other functional outcomes in youth with SCD. Clinically, these findings support the need to acknowledge and address the role that sleep plays in responding to SCD pain in pediatric populations.

Racial and ethnic disparities in sleep outcomes among urban children with and without asthma

BACKGROUND

Suboptimal sleep has been documented in at-risk groups such as urban minority children, particularly those with asthma. It is therefore critical to examine differences in sleep outcomes across specific racial and ethnic groups and to identify factors that contribute to such variations in sleep outcomes to inform tailored interventions to improve sleep health.

OBJECTIVES

The objectives were to examine racial/ethnic differences in sleep outcomes among urban children with and without asthma and to evaluate the extent to which asthma status and aspects of sleep hygiene and the sleep environment contribute to racial/ethnic differences in sleep outcomes in this sample.

METHODS

Two hundred and sixteen African American, Latino, or non-Latino white (NLW) urban children, ages 7-9 years, with (n = 216) and without asthma (n = 130) and their primary caregivers were included. Objective sleep duration and efficiency were assessed via actigraphy. Asthma status was assessed by a study clinician. Caregiver-reported sleep hygiene and exposure to noise were assessed using a questionnaire.

RESULTS

Minority children in the sample had, on average, shorter sleep duration compared to NLW children during the monitoring period (mean difference Latino vs NLW = -22.10, SE = 5.02; mean difference AA vs NLW = -18.69, SE = 5.28) Additionally, several racial/ethnic group differences in sleep outcomes emerged and were dependent on whether or not children had asthma. Specifically, Latinos had lower mean number of awakenings compared to NLWs but only among control participants with no asthma. Furthermore, specific aspects of sleep hygiene and exposure to nighttime noise in the home and neighborhood contributed to racial/ethnic differences in sleep outcomes.

CONCLUSION

Considering urban stressors and asthma status when treating pediatric populations is important, as factors related to urban stress and asthma management may influence sleep hygiene practices and sleep outcomes.

Association Between Parental Educational Attainment and Youth Outcomes and Role of Race/Ethnicity

Importance

The concept of minorities' diminished returns refers to the smaller protective effects of educational attainment for racial and ethnic minority groups compared with those for majority groups.

Objective

To explore racial and ethnic differences in the associations between parental educational attainment and youth outcomes among US adolescents.

Design, Setting, and Participants

A cross-sectional study was performed of 10 619 youth aged 12 to 17 years who were participants at wave 1 of the Population Assessment of Tobacco and Health (PATH) study, a nationally representative survey, in 2013. Data analysis was performed from August to October 2019.

Main Outcomes and Measures

The dependent variables were youth tobacco dependence, aggression, school performance, psychological distress, and chronic medical conditions. The independent variable was parental educational attainment. Age and sex of the adolescents and marital status of the parents were the covariates. Race and ethnicity were the moderating variables. Logistic regression was used for data analysis.

Results

Among the participants, 5412 (51.0%) were aged 12 to 15 years, and 5207 (49.0%) were aged 16 to 17 years; 5480 (51.7%) were male. For non-Hispanic white youth, as parental educational attainment increased, there were stepwise reductions in the prevalence of tobacco dependence (13.2% vs 6.9% vs 2.7%), aggression (37.9% vs 34.8% vs 26.1%), low grade point average (84.2% vs 75.6% vs 53.3%), and chronic medical conditions (51.7% vs 50.8% vs 43.9%), but there was not such a trend for psychological distress (43.7% vs 48.6% vs 41.0%). Interactions were significant between Hispanic ethnicity and parental education on tobacco dependence (OR, 3.37 [95% CI, 2.00-5.69] for high school graduation; OR, 5.40 [95% CI, 2.52-11.56] for college graduation; P < .001 for both), aggression (OR, 1.41 [95% CI, 1.09-1.81]; P = .008 for high school graduation; OR, 1.59 [95% CI, 1.14-2.21]; P = .006 for college graduation), and psychological distress (OR, 1.50 [95% CI, 1.05-2.13]; P = .03). Black race showed an interaction with college graduation on poor school performance (OR, 2.00 [95% CI, 1.26-3.17]; P = .003) and chronic medical conditions (OR, 1.56 [95% CI, 1.14-2.14]; P = .005). All these findings suggest that the protective associations between high parental educational attainment and youth development might be systemically smaller for Hispanic and black youth than for non-Hispanic youth.

Conclusions and Relevance

Although high parental educational attainment is associated with better outcomes for youth, this association is systemically less significant for Hispanic and black than non-Hispanic white youth. The result is an increased health risk in youth from middle class black and Hispanic families. Given the systemic pattern for outcomes across domains, the diminishing returns of parental educational attainment may be due to upstream social processes that hinder ethnic minority families from translating their capital and human resources into health outcomes.

Poor sleep and adolescent obesity risk: a narrative review of potential mechanisms

Poor sleep is related to increased obesity risk in adolescents, though the mechanisms of this relationship are unclear. This paper presents a conceptual framework of the various pathways that have been proposed to drive this relationship. In this framework, increased food reward, emotional reactivity, decreased inhibitory control, metabolic disturbances, poorer dietary quality, and disrupted meal timings may increase the likelihood of increasing overall energy intake. This paper further notes how poor sleep increases sedentary behavior and screen time, which likely limits overall energy expenditure. The model posits that these mechanisms result in an imbalance of energy intake and expenditure following poor sleep, intensifying the overall risk for obesity. Increases in food reward processes, decreases in insulin sensitivity, disrupted meal timing, and increases in sedentary behavior seem to be the most compelling mechanisms linking poor sleep with increased obesity risk in adolescents. Future directions and clinical implications of this framework are discussed.

Adolescent Sleep: Challenges and Solutions for Pediatric Primary Care

As pediatricians, we can all recall an adolescent patient who presents with fatigue. She is groggy in the morning before school, sometimes nods off in class, and then drinks a caffeinated beverage in the afternoon. She sends text messages to friends before going to bed shortly after midnight. After getting a bit of history from her, the parents complain that she has poor sleep habits while the teenage yawns and then rolls her eyes at being outed. For many adolescents, sleep restriction is a conscious choice that is made, as teens are juggling school responsibilities, extracurricular activities, and social interactions. This article is intended to help primary care pediatricians understand the causes of insufficient sleep in teenagers and gives tips on how to address common sleep issues. There is serious morbidity associated with poor sleep in adolescents, including mood disorders such as depression and anxiety, increased obesity risk, and higher rates of drowsy driving. It is my hope that a few tips from this article will help prevent some of these serious sequelae. [Pediatr Ann. 2019;48(8):e292-e295.].

Toddler Bedtime Routines and Associations With Nighttime Sleep Duration and Maternal and Household Factors

STUDY OBJECTIVES

The aims of this study were to examine (1) relationships among implementing a bedtime routine, nighttime awakenings, and nighttime sleep duration in toddlers from low-income, minority families and (2) differences in maternal and household characteristics between mothers who did versus those who did not implement a nightly bedtime routine for their toddler.

METHODS

Data were collected from mothers of toddlers on maternal and household characteristics and toddler sleep, measured using the Children's HealthWatch Survey and the Extended Brief Infant Sleep Questionnaire (BISQ). A path analysis model was tested to investigate whether nighttime awakenings mediated the relation between implementing a bedtime routine and toddlers' nighttime sleep duration. Chi-square tests were conducted to examine differences in maternal and household characteristics (ie, maternal depressive symptoms, food, housing and energy insecurity) between mothers who did versus those who did not implement nightly bedtime routines over the past 2 weeks.

RESULTS

Implementing a bedtime routine was associated with longer toddler sleep duration through a decrease in nighttime awakenings (β = 5.04, 95% confidence interval = 0.61 to 11.35). More consistent sleep routine implementation was associated with fewer nighttime awakenings and longer sleep duration. Maternal depressive symptoms, housing insecurity, and food insecurity were associated with decreased likelihood of implementing a nightly bedtime routine.

CONCLUSIONS

Maternal depressive symptoms, food insecurity, and household insecurity (factors associated with low socioeconomic status) may be associated with a negative sleep environment and poor toddler sleep quality, potentially because of decreased implementation of bedtime routines.

COMMENTARY

A commentary on this article appears in this issue on page 821.

Adolescent profiles of ethnicity/race and socioeconomic status: Implications for sleep and the role of discrimination and ethnic/racial identity

The present study seeks to explore the intersectionality of ethnicity/race and socioeconomic status (SES) among ethnic/racial minority adolescents in their developmental contexts, examining its implications for sleep disparities and the roles of discrimination and ethnic/racial identity (ERI; i.e., adolescents' understanding and feelings about who they are in relation to their ethnic/racial group). With 350 adolescents (Asian 41.4%, Black, 21.7%, and Latinx 36.9%, female=69.1%, Mage=14.27), we conducted a latent class analysis (LCA) to identify latent classes of adolescents' ethnicity/race, ethnic/racial diversity in their schools and neighborhoods along with SES of their families, schools, and neighborhoods. Next, with hierarchical regression, we tested the association between class membership and subjective and objective sleep duration and quality, followed by the moderating effect of discrimination and ERI. We expected to find adolescents living in low diversity and low SES across various developmental contexts to experience lower levels of subjective and objective sleep duration and quality compared to their counterparts. We also expected to find exacerbating effects of discrimination and ERI exploration, and protective effects of ERI commitment in these associations. Three latent groups were identified (C1: "Black/Latinx adolescents in low/moderate SES families in varying diversity and low SES schools and neighborhoods," C2: "Predominantly Latinx adolescents in low SES families and moderate diversity and SES schools and neighborhoods," and C3: "Predominantly Asian adolescents in low/moderate SES families in moderate/high diversity and SES schools and neighborhoods"). The class memberships to C1 and C2 were associated with compromised sleep duration and quality compared to C3. An interaction effect of discrimination was found for C1 in subjective sleep duration and for C2 in objective sleep duration. While no interactions were found for ERI, ERI commitment had a direct association with objective sleep duration and quality. Interpretations and implications for intersectionality approach in studies on sleep disparities and the roles of discrimination and ERI are discussed.

Prenatal particulate air pollution exposure and sleep disruption in preschoolers: Windows of susceptibility

BACKGROUND

The programming of sleep architecture begins in pregnancy and depends upon optimal in utero formation and maturation of the neural connectivity of the brain. Particulate air pollution exposure can disrupt fetal brain development but associations between fine particulate matter (PM_2.5) exposure during pregnancy and child sleep outcomes have not been previously explored.

METHODS

Analyses included 397 mother-child pairs enrolled in a pregnancy cohort in Mexico City. Daily ambient prenatal PM_2.5 exposure was estimated using a validated satellite-based spatio-temporally resolved prediction model. Child sleep periods were estimated objectively using wrist-worn, continuous actigraphy over a 1-week period at age 4-5 years. Data-driven advanced statistical methods (distributed lag models (DLMs)) were employed to identify sensitive windows whereby PM_2.5 exposure during gestation was significantly associated with changes in sleep duration or efficiency. Models were adjusted for maternal education, season, child's age, sex, and BMI z-score.

RESULTS

Mother's average age was 27.7 years, with 59% having at least a high school education. Children slept an average of 7.7 h at night, with mean 80.1% efficiency. The adjusted DLM identified windows of PM_2.5 exposure between 31 and 35 weeks gestation that were significantly associated with decreased sleep duration in children. In addition, increased PM_2.5 during weeks 1-8 was associated with decreased sleep efficiency. In other exposure windows (weeks 39-40), PM_2.5 was associated with increased sleep duration.

CONCLUSION

Prenatal PM_2.5 exposure is associated with altered sleep in preschool-aged children in Mexico City. Pollutant exposure during sensitive windows of pregnancy may have critical influence upon sleep programming.

"Let's talk about sleep": a qualitative examination of levers for promoting healthy sleep among sleep-deprived vulnerable adolescents

OBJECTIVE

Deficient sleep is highly prevalent in disadvantaged adolescents and contributes to a range of adverse health and behavioral outcomes. We examined mediating mechanisms and strategies that adolescents adopt to improve sleep, and possible levers for promoting sleep in this population.

METHODS

We conducted three focus groups (N = 27 total, age 14-18 years) in adolescents living in low- and middle-income racially/ethnically diverse neighborhoods of Boston, Massachusetts. Participants completed a survey on their sleep and health habits prior to the moderator-led discussions. Discussions were audio-recorded, transcribed, and thematically analyzed.

RESULTS

The study population did not meet the minimum sleep recommendations, and we found a high prevalence of "social jet-lag." We also identified a disconnect between the acknowledgment of the importance of sleep and actual behavior, especially for electronic use. Phone use and screen time were the most commonly cited barriers to a good night's sleep, along with caffeine consumption, which was also high in this sample. There was also a general lack of awareness of sleep hygiene practices and recommendations. Participants reported regulating food intake and physical activity, using allopathic sleep aids, creating a comfortable sleeping environment, and a routine as some strategies to improve sleep.

CONCLUSION

Results from this study suggest facilitating the linkage between participant-generated mediating factors and strategies for better-designed interventions. These include making the negative impact of sleep on health more explicit, improving youth awareness about sleep hygiene, targeting caffeine consumption and electronic use, and introducing sleep recommendations through appropriate and effective channels.

Family contexts and sleep during adolescence

Sleep deprivation among adolescents has received much attention from health researchers and policymakers. Recent research indicates that variation in sleep duration from night to night is associated with multiple health outcomes. While there is evidence that sleep deprivation is socially patterned, we know little about how social contexts are associated with nightly sleep variation during adolescence (a life course stage when nightly sleep variation is particularly high). Given the importance of family environments for influencing adolescents’ sleep patterns, we hypothesized that disadvantaged family contexts would be associated with higher intra-individual variation (IIV) in nightly sleep duration, in addition to lower average nightly sleep duration. We tested these hypotheses in a diverse, population-based sample of 11–17 year-olds (N = 1095) from the Adolescent Health and Development in Context Study. Using survey and ecological momentary assessment data and a novel form of multi-level regression modeling (location-scale mixed modeling), we found that adolescents living in unmarried-parent, low SES, economically insecure, and high caregiver stress families had higher IIV in sleep than adolescents in families with more resources and less caregiver stress. There were fewer family effects on average sleep duration. This suggests family social and economic contexts are associated with an under-researched aspect of adolescent sleep, nightly variation, and may contribute to adolescent sleep problems with implications for their health and health disparities.

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Consistency in nightly sleep duration is important for adolescent health.

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SES and family stress associated with variability in sleep duration in adolescents.

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Caregiver distress also associated with lower mean sleep duration among adolescents.

Racial disparities and sleep among preschool aged children: a systematic review

Sleep disorders and sleep insufficiency are common among preschool-aged children. Studies among school-aged children show disordered sleep is often more prevalent among racial minority groups. The primary aim of this systematic review was to critically appraise empirical data to elucidate the relationship between race and key sleep variables among children aged 2 to 5 years old. By systematically searching PubMed, Web of Science, and EBSCO databases, we identified empirical research articles conducted in the United States that investigate this relationship. We searched for variables relevant to (1) insufficient sleep duration, (2) poor sleep quality, (3) irregular timing of sleep, including sleep/wake problems and irregular bedtime onset and wake times (4) and sleep/circadian disorders. Nine studies satisfied the criteria for inclusion: five investigated nocturnal sleep duration, five investigated bedtime-related variables, four investigated daytime sleep (napping), three investigated total sleep, two investigated sleep quality, and one investigated wake times. Four studies specifically addressed racial and demographic differences in sleep variables as the primary aim, while the remaining five contained analyses addressing racial and demographic differences in sleep as secondary aims. Non-Hispanic white, white, or European-American race was used as the reference category in all studies. The results provided consistent evidence that white, non-Hispanic children were more likely to go to bed earlier and more regularly, have longer nocturnal sleep, and nap less than most racial and ethnic minorities. Combined, this literature presents a compelling narrative implicating race as an important factor in sleep patterns among a preschool age population.