Parent and adolescent reports in assessing adolescent sleep problems: results from a large population study

Exploring the influence of social relationships on adolescents' multiple sleep problems via a school-based China education panel survey: the moderating role of depressive emotion

BACKGROUND

Poor adolescent sleep health is a significant public health issue worldwide. In particular, multiple sleep problems disturb the lives of adolescents. It is urgent to identify the key factors (e.g., parent‒child relationships, peer relationships, and teacher‒student relationships) and influential moderators (e.g., depressive emotions) that contribute to adolescent sleep problems.

METHODS

Data were derived from the China Education Panel Survey (CEPS) and collected through self-reported questionnaires. A total of 7405 students (3818 boys and 3587 girls) born between 2000 and 2001 were followed from grade 7 through grade 8. Logistic regression was applied to explore the effects of the independent variables and moderating variable on students' sleep problems.

RESULTS

Remaining fatigued after waking up (17.97%), dreaminess (14.21%) and sleep fragmentation (13.07%) were the three most common sleep problems among the students. Peer relationships, teacher praise, and depressive emotions were related to adolescents' sleep problems (all p < 0.05). Notably, depressive emotion served as an influential moderator in the relationship between social relationships and sleep problems among students, exhibiting simultaneous and lasting effects (all p < 0.05).

CONCLUSIONS

Reducing adolescents' sleep problems is necessary, and enhancing adolescents' positive social relationships and reducing their depressive emotions should receive increased attention.

Psychometric examination of the patient-reported outcome measurement information system parent proxy pediatric sleep measures from early childhood to adolescence in a nationally representative Spanish sample

STUDY OBJECTIVES

To use a nationally representative sample to (1) evaluate the factor structure of the patient-reported outcome measurement information system (PROMIS) parent proxy pediatric sleep scales (Spanish translation), (2) examine the invariance of these scales across sex and across different developmental periods of childhood and adolescence, (3) confirm the information and precision of the scales using item response theory (IRT), and (4) provide age-based normative information.

METHODS

Parents of a nationally representative sample of 5525 Spanish children and adolescents ages 5-16 years (56.1% boys) completed the Spanish translation parent proxy short versions of the sleep disturbance and sleep-related impairment scales. We conducted confirmatory factor analyses, invariance analyses, and graded-response IRT analyses.

RESULTS

CFAs conducted separately on males and females within three age groups (early childhood: ages 5-8 years; middle childhood: ages 9-12 years; adolescence: ages 13-16 years) indicated all items had a substantial loading with one exception (the sleep continuity item ["my child slept through the night"] had a substantially lower loading and was removed for subsequent analyses). The scores on the two scales demonstrated invariance across sex within each age group. Using IRT analyses, both scales showed a high degree of information and precision from slightly below the trait means to slightly above two standard deviations above the trait means.

CONCLUSIONS

The strong psychometric properties of the short versions of the parent proxy PROMIS pediatric sleep disturbance and sleep-related impairment scales, coupled with age-based norms, suggest these scales are likely to be useful for research and clinical applications.

Cognitive and Behavioral Outcomes of Snoring Among Adolescents

Importance

Snoring is central to sleep-disordered breathing (SDB), which arises from nocturnal upper airway resistance. Habitual snoring is associated with cognitive and behavioral problems in young children, but less is known about these associations in adolescents.

Objective

To assess the longitudinal associations of snoring with cognition and problem behaviors among adolescents.

Design, Setting, and Participants

This cohort study was a secondary analysis of the Adolescent Brain Cognitive Development (ABCD) Study dataset (release 5.0), which enrolled 11 875 children and a parent or caregiver from June 1, 2016, to October 15, 2018, at 21 participating US research institutions and followed-up for 5 years. The analysis was performed between December 2023 and April 2024.

Exposures

Parent-reported snoring categorized as none, nonhabitual (<3 nights/week), and habitual (≥3 times/week).

Main Outcomes and Measures

Cognition was assessed using 5 measures from the National Institutes of Health Toolbox (NIH-TB), and caregiver-reported problem behaviors were assessed using the Child Behavior Checklist (CBCL), including Total Problems, Internalizing Problems, and Externalizing Problems. Longitudinal associations of snoring with these assessment measures were analyzed using linear mixed-effects models stratified by obesity. Model fits were assessed after including the fixed-effects of age, sex at birth, race, family income, follow-up time, visit type, and the random-effects of site and identification number.

Results

The study included data from 11 862 children at year 1 (mean age, 119.0 months [95% CI, 118.8 to 119.1 months]; 6164 male [52.2%]) and 11 198, 10 870, 10 064, and 4668 children at years 2 to 5, respectively. The proportion of habitual snorers decreased from 811 participants (6.8%) in year 1 to 150 participants (3.2%) in year 5. Snoring was not associated with any of the NIH-TB scores. A statistically significant association of snoring was identified with all CBCL scales. The largest-magnitude association was of snoring with the CBCL Total Problems scale among adolescents with obesity (β = 3.18; 95% CI, 2.59-3.77).

Conclusions and Relevance

In this cohort study analyzing associations of snoring with cognitive test scores and problem behaviors based on the ABCD dataset, the prevalence of snoring declined over time; snoring in adolescents was associated with problem behaviors but not cognitive deficits. These findings may aid shared decision-making regarding treatment options such as adenotonsillectomy for adolescents with SDB.

Physiological and Family-Level Correlates of Autistic Adolescents' Sleep Quality

PURPOSE

Autistic adolescents commonly experience sleep-related difficulties and prior studies have sought to separately examine physiological and family-level predictors of their sleep quality. The current study aimed to conceptually replicate and extend to an adolescent sample a prior study that found respiratory sinus arrhythmia was associated with sleep quality in autistic children. In addition, the current study also examined whether the quality of the family environment was associated with sleep quality in autistic adolescents.

METHODS

The sample consisted of 107 autistic adolescents who completed a baseline measure of respiratory sinus arrhythmia and then watched a video of their parents engaged in a discussion about a topic of disagreement while their respiratory sinus arrhythmia reactivity was measured. Adolescents also completed questionnaires measuring their sleep quality and family environment.

RESULTS

In regression models, adolescents' physiological functioning was not a significant predictor of their sleep quality; however, adolescents living in poorer quality family environments reported worse sleep quality after controlling for their physiological functioning. The interaction between physiological functioning and the family environment predicting sleep quality was non-significant.

CONCLUSION

Although the current study did not conceptually replicate prior work, the findings highlight the importance of the family environment for adolescents' sleep. Implications and future directions are discussed.

The unique role of adolescent internalizing and externalizing problems, and maternal-adolescent communication in their association with attachment in early adulthood

Attachment styles influence mental health and relationships through life. Few studies examine the adolescent factors associated with adult attachment styles. This paper examines the association between adolescent emotional and behavioral problems and maternal-adolescent communication with attachment style in early adulthood. Data from 3423 participants in a birth cohort study were examined. At 14-years, participants' mothers completed the Parent-Adolescent Communication Scale. Participants completed the Youth Self-Report at 14-years which measures internalizing and externalizing symptoms, and the Attachment Style Questionnaire (ASQ) at 21-years. The ASQ comprises five domains of internal working models of interpersonal relationships and attachment style: confidence (security), discomfort with closeness and relationships as secondary (avoidance), need for approval and preoccupation with relationships (anxiety). Associations were examined using general linear models. After adjustments, internalizing symptoms score was associated with all domains of attachment and externalizing symptoms score was associated with four domains of attachment insecurity, but not attachment security. Low openness in maternal-adolescent communication was most strongly associated with decreased confidence and high problem maternal-adolescent communication was associated with viewing relationships as secondary. Adolescents with emotional and behavioral problems and maternal-adolescent communication may benefit from attachment-based interventions to support the development of healthy relationships and attachments in young adulthood.

Demographic, lifestyle, social, and psychological factors associated with worry-related sleep problems among school-going adolescents in Timor-Leste

OBJECTIVE

Adolescent sleep problems are a worldwide public health issue. The present study examines factors associated with worry-related sleep problems among school-going adolescents. The country of interest is Timor-Leste, a low-income country, where studies pertaining to adolescent sleep problems are lacking.

DESIGN AND MEASURES

Data were analysed from the Global School-Based Student Health Survey Timor-Leste (n = 3455). An ordered probit model was used to assess the effects of demographic, lifestyle, social, and psychological factors on different levels of worry-related sleep problems (i.e., no, mild and severe sleep problems).

RESULTS

School-going adolescents were more likely to face mild or severe worry-related sleep problems if they were older, passive smokers, alcohol drinkers and moderately active. School-going adolescents who sometimes or always went hungry were more likely to experience worry-related sleep problems than those who did not. Involvement in physical fights, being bullied, and loneliness were positively associated with the probability of having modest or severe worry-related sleep problems.

CONCLUSION

Age, exposure to second-hand smoke, alcohol consumption, physical activity, going hungry, physical fights, being bullied and loneliness are the important determining factors of adolescent worry-related sleep problems. Policymakers should pay special attention to these factors when formulating intervention measures.

Psychosocial determinants of sleep difficulties in adolescence: the role of perceived support from family, peers, and school in an Italian HBSC sample

The present study explores the concurrent contribution to sleep problems of individual-related, family-related, and school-related factors in adolescence. Gathering from the Italian 2018 Health Behavior in School-Aged Children (HBSC) data collection, we used hierarchical logistic regression on a sample of 3397 adolescents (51% females, Mage = 13.99, SD = 1.62) to explore the contribution to sleep problems of the individual (Model 1: alcohol use, smoking, screen time, physical activity), familial (Model 2: parental communication, parental support), and school-related (Model 3: peer support, schoolmates/students support, teacher support and school pressure) variables. 28.3 percent of adolescents reported having sleep difficulties. Overall, Model 3 significantly improved over Model 2 and Model 1. Data showed that increasing smoking (OR = 1.11; 95% CI: 1.03-1.20) and screen time (OR = 1.05; 95% CI: 1.02-1.08) were associated with sleep difficulties but not alcohol use and physical activity. Also, impaired communication with both parents and increasing parental support (OR = 0.84; 95% CI: 0.78-0.90) were associated with decreased odds of sleep problems. Finally, both increases in school pressure (OR = 1.40; 95% CI: 1.26-1.56) and lack of student support (OR = 1.25; 95% CI: 1.10-1.42) were associated with a higher likelihood of sleep problems, while peer support and teacher support were not.   Conclusion: Our findings highlight the importance of an integrated approach to the study of sleep difficulties in adolescence that includes specific psychosocial contributors such as the quality of parental communication and perceived parental support and considers the quality of the day-to-day relationship with schoolmates and the school level of demands. What is Known: • Adolescents' are at-risk of more significant sleep difficulties, and recent literature highlights the importance of an integrated approach to understanding this phenomenon, including biological, psychosocial, and contextual factors. • The literature lacks findings that consider the concurrent contribution of individual and psychosocial factors to sleep difficulties in adolescence. What is New: • The quality of parental communication and perceived parental support, as expressions of adult figures' emotional and behavioural availability in the adolescent's life, are significant determinants of sleep difficulties. • The quality of day-to-day relationships with schoolmates and the school level of demands contribute to adolescent sleep problems.

Predictors of Sleep-Problem Trajectories Across Adolescence

Stress and sleep problems are significantly correlated in adolescents. Few longitudinal studies, however, have evaluated possible correlates and predictors of sleep problems at multiple points across adolescence. The current study examined the relation between stress and sleep problems across four years in a sample of adolescents who varied in risk for psychopathology. Participants included 223 adolescents (55% female) and 223 mothers (77% with a history of a mood disorder during their child's life). Youth were evaluated in grade 7 (M = 12.69 years, SD = 0.61) and again in grades 8, 9, and 11. Sleep problems were assessed as part of a clinical interview, and weekly stressful events were measured with the Life Events Interview for Adolescents. Multi-group latent growth curve analyses were conducted. Among youth whose mothers had a history of depression (high-risk), sleep problems significantly increased over time (p < .001). Second, among high-risk youth, at each time point, higher stress levels during the prior three months significantly predicted higher levels of sleep problems (p < .001). Finally, across the entire sample, at each time point a greater level of sleep problems predicted higher stress ratings a year later (p ≤ .001). Thus, stress was a significant predictor of sleep problems across multiple years of adolescence, particularly among offspring of mothers with a history of depression. Results highlight targets for preventive interventions for sleep problems in youth.

Context-dependent irritability in Attention Deficit/Hyperactivity Disorder: correlates and stability of family-restricted versus cross-situational temper outbursts

BACKGROUND

Impairing irritability is highly prevalent in children with attention deficit/hyperactivity disorder (ADHD), although manifestations of irritability are not necessarily present in all settings (home, school, with peers). At the moment, little is known about the relative prevalence, stability, and etiologies of contextual versus cross-situational manifestations of irritability in ADHD. In this study, levels of dysfunctional parenting practices and sleep problems were compared in irritable versus nonirritable children with ADHD, in cases of family-restricted versus cross-situational irritability, and examined as predictors of irritability levels over a one-year interval. Stability of irritability manifestations over time was investigated, and prevalence of cross-situational disruptive mood dysregulation disorder (DMDD) versus 'family-restricted' DMDD was compared.

METHOD

One hundred and seventy children with ADHD (age 6-11) were examined. Parents completed a semi-structured interview and questionnaire to assess irritability, and parent-report questionnaires were used to evaluate parenting practices and sleep problems. Questionnaires were completed for a second time after a one-year interval.

RESULTS

Parenting practices were more dysfunctional in the irritable group compared to the nonirritable group, while sleep problems did not differ between these two groups. Levels of parenting practices and sleep problems did not predict later irritability after correction for multiple comparison nor did they differ between the family-restricted and cross-situational irritable groups. Finally, family-restricted irritability was as prevalent and as stable over time as cross-situational irritability and family-restricted DMDD as prevalent as cross-situational DMDD.

CONCLUSIONS

Factors associated with contextual versus cross-situational manifestations of irritability in ADHD remain elusive. More subtle measures of parenting practices should be considered, including psychological control or accommodation, and other constructs such as social inhibition. Despite not being captured by current nosography, severe forms of family-restricted irritability may be as prevalent as severe forms of cross-situational irritability.

Evidence Base Update on Assessing Sleep in Youth

BACKGROUND

Sleep is vital to youth well-being and when it becomes disturbed - whether due to environmental or individual factors - mental and physical health suffer. Sleep problems can also be a symptom of underlying mental health disorders. Assessing different components of sleep, including quality and hygiene, can be useful both for identifying mental health problems and for measuring changes in well-being over time. However, there are dozens of sleep-related measures for youth and it can be difficult to determine which to select for a specific research or clinical purpose. The goal of this review was to identify sleep-related measures for clinical and/or research use in youth mental health settings, and to update the evidence base on this topic.

METHOD

We generated a list of candidate measures based on other reviews and searched in PubMed and PsycINFO using the terms "sleep" AND (measure OR assessment OR questionnaire) AND (psychometric OR reliability OR validity). Search results were limited to studies about children and adolescents (aged 2-17) published in English. Additional criteria for inclusion were that there had to be at least three publications reporting on the measure psychometrics in community or mental health populations. Sleep measures meeting these criteria were evaluated using the criteria set by De Los Reyes and Langer (2018).

RESULTS

Twenty-six measures, across four domains of sleep - insomnia, sleep hygiene, sleepiness, sleep quality - met inclusion criteria. Each measure had at least adequate clinical utility. No measure(s) emerged as superior across psychometric domains.

CONCLUSION

Clinicians and researchers must evaluate sleep measures for each use case, as the intended purpose will dictate which measure is best. Future research is necessary to evaluate measure performance in transdiagnostic mental health populations, including youth with serious mental illness.

High occurrence of sleep problems in survivors of a childhood brain tumor with neurocognitive complaints: The association with psychosocial and behavioral executive functioning

BACKGROUND

Survivors of childhood brain tumors are prone to sleep and neurocognitive problems. Effective interventions to improve neurocognitive functioning are largely lacking. In general, sleep problems are negatively related to neurocognitive functioning, but this relationship is unclear in survivors of childhood brain tumors. Therefore, the occurrence of sleep problems, potential risk factors, and the relation between sleep and executive functioning were evaluated.

PROCEDURE

Baseline data of a randomized controlled trial on the effectiveness of neurofeedback were used. Childhood brain tumor survivors 8-18 years of age with parent-reported neurocognitive complaints ≥2 years after treatment were eligible. Parents completed the Sleep Disturbance Scale for Children. Executive functioning was assessed by parents and teachers (Behavior Rating Inventory of Executive Functioning). Multiple linear regression analyses were used to examine sociodemographic and medical characteristics and emotional difficulties and hyperactivity/inattention (Strength and Difficulties Questionnaire) as potential risk factors for sleep problems, and to assess the association between sleep and executive functioning.

RESULTS

Forty-eight percent of survivors (n = 82, 7.0 ± 3.6 years post diagnosis, age 13.8 ± 3.2 years) had sleep problems and scored significantly worse than the norm on the subscales Initiating and Maintaining Sleep, Excessive Somnolence, and the total scale (effect sizes 0.58-0.92). Emotional problems and/or hyperactivity/inattention were independent potential risk factors. Sleep problems were associated with worse parent-reported executive functioning.

CONCLUSIONS

Sleep problems occur among half of childhood brain tumor survivors with neurocognitive problems, and are associated with worse executive functioning. Future studies should focus on the development of sleep interventions for this population, to improve sleep as well as executive functioning.

The effects of family dysfunction trajectories during childhood and early adolescence on sleep quality during late adolescence: Resilience as a mediator

RATIONALE

Sleep quality has been linked to several behavioral and psychological problems. No longitudinal study has examined the associations and underlying mechanisms between the trajectories of family characteristics and sleep quality in adolescents.

OBJECTIVE

This study investigates the effects of heterogeneous trajectories of family dysfunction on sleep quality in adolescents and examines whether resilience mediates these associations.

METHOD

Data came from 2280 adolescents participating in a longitudinal study across grades 2 through 11 in northern Taiwan. Group-based trajectory modeling was used to identify discrete developmental patterns of family dysfunction. Multiple linear regression was applied to examine the associations between family dysfunction trajectories and sleep quality. Mediation analysis was conducted to test whether resilience mediates the associations examined.

RESULTS

Four distinct trajectories of family dysfunction were identified: low persistent (26%), escalating dysfunction (21%), moderate stable (25%), and high persistent (28%). Compared to adolescents in the low-persistent trajectory, those in the escalating-dysfunction, moderate-stable, and high-persistent trajectories had significant lower levels of sleep quality (B = -0.19, p < .001, B = -0.14, p < .01, and B = -0.13, p < .05, respectively). Resilience significantly mediated the effects of all family dysfunction trajectories (relative to the low-persistent trajectory) on sleep quality (95% bootstrap confidence intervals are -0.06 to -0.02, -0.05 to -0.02, and -0.08 to -0.03 for escalating-dysfunction, moderate-stable, and high-persistent trajectories, respectively).

CONCLUSIONS

Family dysfunction conferred risks for poor sleep quality in adolescents and the negative effects, in part, were through decreasing resilience. Interventions to improve sleep quality in adolescents by targeting family function may be more effective when incorporating resilience.

Prenatal and early life origins of adolescence sleep problems: evidence from a birth cohort

PURPOSE

This study aims to identify the prenatal and early life predictors of adolescence sleep problems.

METHODS

Sleep data (n = 5081) from the 14-year (13.92 ± 0.34 years) follow-up of a birth cohort were analyzed to explore the predictors of adolescence trouble sleeping, nightmares, snoring and sleep talking/walking. Data from the antenatal period till adolescence were explored for identifying predictors of adolescence sleep problems. Modified Poisson regression with a robust error variance was used to identify significant predictors.

RESULTS

Our results suggest that about a quarter of adolescents in our study sample had sleep maintenance problems (nightmares: 27.88%, snoring: 23.20%, sleepwalking/talking 27.72%). The prevalence rate of sleep initiation problems was even higher (trouble sleeping: 40.61%). Our results suggest that antenatal and early-life factors, e.g. maternal smoking, anxiety, sleep problems in childhood, attention deficit hyperactivity disorder (ADHD) symptoms, and poor health are significant predictors of adolescence sleep problems.

CONCLUSIONS

This study demonstrates the predictive role of prenatal and early life risk factors in adolescence sleep problems. It seems that exposure to prenatal and early life risk factors increase the vulnerability for sleep problems later in life, which is further supported by poor health and lifestyle choices in adolescence. Therefore, close observation and mitigation of factors associated with early life risk factors could be a potential strategy for preventing sleep problems later in life.

Early intervention for adolescents at-risk for bipolar disorder: A pilot randomized trial of Interpersonal and Social Rhythm Therapy (IPSRT)

OBJECTIVE

To conduct a pilot randomized trial of Interpersonal and Social Rhythm Therapy plus Data-Informed Referral (IPSRT + DIR) versus DIR-alone for adolescents at-risk for bipolar disorder (BP).

METHOD

Eligible participants included youth (12-18) with a BP parent; youth with BP were excluded. Participants (n = 42) were randomized to receive IPSRT + DIR to treat any psychiatric disorders present at baseline, or DIR-alone. A blind evaluator assessed outcomes at baseline, 3- and 6-months. Participants wore an actigraph to measure sleep/wake patterns for 7 days at baseline and 6-months. Primary outcomes included mood and non-mood symptoms and sleep disturbance.

RESULTS

Youth randomized to IPSRT + DIR attended approximately half of scheduled IPSRT sessions. Although 33% of DIR-alone youth were referred for mental health services at intake (another 33% were already engaged in services), none initiated new services over follow-up. No youth developed new-onset mood disorder over follow-up. Self- and parent-reported mood and non-mood psychiatric symptoms did not distinguish the groups, although youth in DIR-alone tended to have higher baseline scores on most measures. Per clinician ratings, 1 youth receiving IPSRT + DIR displayed subthreshold hypo/manic symptoms, versus 2 receiving DIR-alone (OR = 14.7, p = 0.03), possibly signaling less subthreshold hypo/manic symptoms, and for fewer weeks (χ²= 11.06, p = 0.0009), over 6-months with IPSRT + DIR. We found a small effect for youth in the IPSRT + DIR group to evidence more WASO at pre-treatment, but less at follow-up (cohen's d = 0.28).

LIMITATIONS

Small sample size limits statistical power, and we are unable to definitively attribute group differences to IPSRT versus greater clinical contact. Ability to examine distal/rare (i.e., BP onset) outcomes was limited.

CONCLUSIONS

Adolescents at-risk for BP present challenges to psychosocial treatment engagement and retention. IPSRT merits further study as an acceptable intervention for at-risk youth, though necessary frequency and intensity to affect outcomes should be examined. The potential to delay or prevent subthreshold hypo/manic symptoms via enhanced sleep continuity is an area for further examination. Future studies with larger samples and extended follow-up can help determine whether IPSRT may delay or prevent syndromal hypo/mania in youth at-risk.

The use of entertainment and communication technologies before sleep could affect sleep and weight status: a population-based study among children

Background

Short sleep duration and poor sleep quality have been demonstrated to be associated with childhood obesity. It has been suggested that electronic entertainment and communication devices (EECDs) including TVs, computers, tablets, video games and cell phones interfere with sleep in children and youth. The aim of this study was to assess the impact that the use of EECDs in the hour before bedtime has on sleep and weight status to inform sleep promotion interventions and programs to prevent childhood obesity.

Methods

A provincially representative sample of 2334 grade 5 children and their parents in Alberta, Canada was surveyed. Parents reported their child’s bedtime and wake-up time along with how often their child snored, felt sleepy during the day, woke-up at night and woke-up in the morning feeling unrefreshed. Sleep duration, sleep quality and sleep efficiency were derived from these indicators. Parents also reported on the presence of EECDs in their child’s bedroom, while children reported use of EECDs during the day and frequency of using each of these devices during the hour before sleep. The height and weight of children were measured. Multivariable mixed effect linear and logistic regression models were used to determine how sleep duration, sleep quality, sleep efficiency and weight status are influenced by (i) access to EECDs in children’s bedrooms, (ii) use of EECDs during the hour before sleep, and (iii) calming activities specifically reading during the hour before sleep.

Results

Sleep duration was shorter by −10.8 min (cell phone), −10.2 min (computer) and −7.8 min (TV) for those with bedroom access to and used these EECDs during the hour before sleep compared to no access and no use. Good sleep quality was hindered by bedroom access to and use of all EECDs investigated during the hour before sleep, particularly among users of cell phones (OR = 0.64, 95% CI: 0.58–0.71) and computers (OR = 0.72, 95% CI: 0.65–0.80). Very good sleep efficiency was decreased by access to and frequent use of a TV (54%), cell phone (52%), tablet (51%) and video games (51%). Odds of obesity were doubled by bedroom access to and use of a TV and computer during the hour before sleep. Children who rarely read a printed book in the bedroom during the hour before sleep had a shorter sleep duration and poorer sleep quality and sleep efficiency compared to their peers. Having access to an EECD in the bedroom was associated with increased obesity despite frequently reading during the hour before sleep.

Conclusions

Our findings suggest that sleep duration, sleep quality, sleep efficiency and weight status are better among children who do not have EECDs in the bedroom and frequently read a book during the hour before sleep as opposed to those who use EECDs during this hour. Education of limits against EECD use by parents may improve sleep outcomes. These findings will inform health promotion messages and may give rise to national recommendations regarding EECD use.

Trial registration

ClinicalTrials.gov NCT01914185. Registered 31 July 2013 Retrospectively registered.