Reliability and validity of a brief sleep questionnaire for children in Japan

Prevalence of bruxism in down syndrome patients: A systematic review and meta-analysis

BACKGROUND

Bruxism is a parafunctional activity characterised by grinding or clenching of teeth and is a common oral health concern in individuals with down syndrome (DS). Understanding the prevalence of bruxism in this population is crucial for developing effective management strategies. This systematic review and meta-analysis is aimed to investigate the prevalence of bruxism among individuals with DS and explore its association with other oral health issues.

METHODS

A comprehensive search was conducted across multiple electronic databases to identify relevant studies. Cross-sectional and observational studies were included. Data on bruxism prevalence and associated factors were extracted, and a meta-analysis was performed using both fixed-effects (FE) and random-effects (RE) models of MedCalc software. Heterogeneity among studies was assessed using I2 statistics. New Castle-Ottawa Scale was used to evaluate methodological quality of the included studies.

RESULTS

Eight studies met the pre-defined inclusion criteria and were included in the analysis. Seven studies used a questionnaire to assess bruxism. The pooled proportion estimate for occurrence of DS across the included studies was found to be 0.33 (95% CI: 0.22-0.45) as per the RE model and 0.35 (95% CI: 0.31-0.450) as per FE model in the quantitative analysis. All studies exhibited good methodological quality.

CONCLUSION

This systematic review and meta-analysis provide evidence of a significant prevalence of bruxism among individuals with DS. The findings highlight the association of bruxism with other oral health issues and specific chromosomal abnormalities. Comprehensive oral health assessments, including diagnostic procedures like Polysomnography, are essential for addressing the unique oral health needs of individuals with DS. Further studies are recommended with a valid tool for the diagnosis. Early interventions and management strategies need to be tailored to this population, considering the multifaceted nature of oral health concerns in individuals with DS.

Sleep problems in children and adolescents in an attention deficit hyperactivity disorder service

OBJECTIVES

Sleep problems are common amongst children and adolescents with attention deficit hyperactivity disorder (ADHD). The purpose of this study was to investigate sleep problems in children and adolescents attending a specialist ADHD service.

METHODS

This was a cross-sectional online survey combined with a retrospective chart review, conducted in the ADHD Assessment, Diagnosis, Management, initiation, Research and Education (ADMiRE) service, the first public specialist ADHD service for young people in Ireland. Participants were caregivers of children and adolescents with ADHD attending ADMiRE. Sleep was assessed using The Children's Sleep Habits Questionnaire (CSHQ) and ADHD symptoms were assessed using an abbreviated version of the Swanson, Nolan and Pelham Teacher and Parent Rating Scale (SNAP-IV). Details regarding patient demographics, co-morbidities and medication were collected from patient records.

RESULTS

Eighty-four percent of young people scored above the clinical cut-off for a sleep disorder. The most frequently reported sleep problems were related to sleep onset and sleep duration, and 64% of respondents met the criteria for two or more sleep problems. ADHD severity was associated with greater sleep problems. Co-morbid physical, neurodevelopmental, and mental health disorders as well as stimulant use were not associated with greater sleep problems.

CONCLUSION

Sleep problems are very common amongst children and adolescents with ADHD. This study has demonstrated an association between more sleep problems and ADHD severity. These findings highlight the need for both effective ADHD treatment to ensure optional sleep in young people as well as effective interventions for sleep problems to prevent worsening of ADHD symptoms.

Diagnostic criteria for temporomandibular disorders-INfORM recommendations: Comprehensive and short-form adaptations for children

BACKGROUND

The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) are used worldwide in adults. Until now, no adaptation for use in children has been proposed.

OBJECTIVE

The aim of this study was to present comprehensive and short-form adaptations of Axis I and Axis II of the DC/TMD for adults that are appropriate for use with children in clinical and research settings.

METHODS

Global Delphi studies with experts in TMDs and in pain psychology identified ways of adapting the DC/TMD for children.

RESULTS

The proposed adaptation is suitable for children aged 6-9 years. Proposed changes in Axis I include (i) adapting the language of the Demographics and the Symptom Questionnaires to be developmentally appropriate for children, (ii) adding a general health questionnaire for children and one for their parents, (iii) replacing the TMD Pain Screener with the 3Q/TMD questionnaire and (iv) modifying the clinical examination protocol. Proposed changes in Axis II include (i) for the Graded Chronic Pain Scale, to be developmentally appropriate for children, (ii) adding anxiety and depression assessments that have been validated in children and (iii) adding three constructs (stress, catastrophising and sleep disorders) to assess psychosocial functioning in children.

CONCLUSION

The recommended DC/TMD, including Axis I and Axis II, for children aged 6-9 years, is appropriate for use in clinical and research settings. This adapted the first version for children includes changes in Axis I and Axis II changes requiring reliability and validity testing in international settings. Official translations to different languages according to INfORM requirements will enable a worldwide dissemination and implementation.

Reliability, validity, and psychometric properties of the Persian version of the Tayside children's sleep questionnaire

Tayside Children's Sleep Questionnaire (TCSQ) is a simple tool for screening the disorders of initiating and Maintaining Sleep among children aged between 1 and 5 years. This study aimed to translate TCSQ into Persian and evaluate its validity and reliability of TCSQ among Persian speakers. This cross-sectional study was conducted among 311 children aged 1-5 years in Isfahan. After permission, the forward-backward translation method was used to develop the Persian version. Finally, 311 children participated in this survey, which 30 were repeated a second time. Google Forms, SPSS16, and STATA14 were used for data collection, descriptive statistics, and factor analysis. BEARS questionnaire was used to assess concurrent validity. Three expert opinions were used for content validity. In this study, 404 mothers of children in Isfahan volunteered to participate in the survey, of which 311 remained. The mean and standard deviation age of their children were 3.47 ± 1.91 years. Cronbach Alpha of the Persian version of TCSQ was 0.76 CI (0.78-0.66). The intra-class correlation coefficient was 0.67 CI (0.60-0.74). The content validity index was 0.88, and three factors (disturbance, nighttime, parents) with a specific value greater than 0.4 is determined by factor analysis. The current study results indicate that TCSQ has good reliability and validity among Persian speakers.

Measuring sleep health in primary school-aged children: A systematic review of instruments and their content validity

Study Objectives

This review aimed to summarize instruments that measure one or more domains of sleep health (i.e. duration, quality, efficiency, timing, daytime sleepiness and sleep-related behaviors) in a general population of 4–12-year old children, and to assess these instruments’ content validity. Other measurement properties were evaluated for instruments with indications of sufficient content validity.

Methods

A systematic literature search was performed in PubMed, PsycINFO, Web of Science, and EmBase. Methodological quality, content validity, and other measurement properties were assessed via the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. Instruments with indications of sufficient content validity (i.e. relevance, comprehensiveness and comprehensibility) were further evaluated on other measurement properties (i.e. other aspects of validity, reliability, responsiveness). A modified GRADE approach was applied to determine the quality of evidence.

Results

Twenty instruments, containing 36 subscales, were included. None of the instruments measured all sleep health domains. For five (subscales of) instruments sufficient relevance and comprehensibility was found. The quality of evidence ranged from very low to moderate. For these five instruments all additional measurement properties were assessed. Sufficient results were found for structural validity (n = 1), internal consistency (n = 1), and construct validity (n = 1), with quality of evidence ranging from very low to high.

Conclusions

Several (subscales of) instruments measuring domains of child sleep health showed good promise, demonstrating sufficient relevance, comprehensibility, and some also sufficient results on other measurement properties. However, more high quality studies on instrument development and the evaluation of measurement properties are required.

PROSPERO registration number: CRD42021224109

Sleep problems, sleep duration, and use of digital devices among primary school students in Japan

BACKGROUND

There is growing concern that screen time and media use in school-age children can negatively affect children's sleep. These negative effects are explained by three main underlying mechanisms: reduced sleep, time allocated for more media consumption; increased mental, emotional, or psychological stimulation by media content; and the effects of light emitted by digital devices on circadian rhythms and sleep physiology and arousal. In this study, we focused not only on sleep duration, but also on sleep problems. We conducted a large-scale survey to examine the relationship between excessive use of digital devices, Internet addictive behaviour, sleep duration, and sleep problems.

METHODS

We conducted a cross-sectional study of children enrolled in 20 public primary schools in Nagoya City, Japan. Children's parents/guardians completed a questionnaire including the brief sleep questionnaire for Japanese children which is a shortened version of the 'Children's Sleep Habits Questionnaire'. Logistic regression analyses were used to identify associations between sleep problems and grade, sex, weekday sleep time, weekend sleep time, ownership of digital devices, frequent checking of digital devices, use of digital devices for more than 4 hours per day, and Internet addiction.

RESULTS

In total, 8172 responses were received (91.6% response rate). After excluding incomplete responses, we analysed complete datasets for 6893 children with a mean age of 9.0 years. When adjusted for sex, grade, sleep duration on weekdays, and sleep duration on weekends, failure to control (odds ratio [OR] = 1.48; 95% confidence interval [CI]: 1.29-1.70; p < .001), more use than intended (OR = 1.27; 95% CI: 1.12-1.44; p < .001), and use to escape a dysphoric mood (OR = 1.30; 95% CI: 1.03-1.64; p = .027) were associated with children's sleep problems. A shorter weekday and a longer weekend sleep duration indicated a higher likelihood of sleep problems.

CONCLUSIONS

After adjusting for sleep duration, a relationship was found between the three Internet addictive behaviours and sleep problems, but not ownership of digital devices. Parents and teachers may need to address screen media-related sleep problems in children, as these problems may be influenced by psychological factors.

The Japanese Sleep Questionnaire for preschoolers within a Malaysian context

BACKGROUND

Childhood sleep practices impact growth, development, and long-term health. There is a paucity of sleep data pertaining to preschool children in Asia, especially South-East Asia.

METHODS

This cross-sectional study involved parents of well siblings, aged 2-6 years. It aimed to: (i) test the reliability of the English version of the Japanese Sleep Questionnaire for Preschoolers (JSQ-P), and (ii) obtain the prevalence, as well as describe, sleep-related issues. Ninety-one (91) parents (74.7%; mothers) self-administered the questionnaire in the pediatric clinic waiting area of a Malaysian tertiary hospital. Recruitment was from August to November 2020.

RESULTS

The English version of the JSQ-P has good internal consistency (Cronbach alpha = 0.85). Range of Cronbach alpha values for each item: 0.36-0.87. Many (77%) children slept at 10:00 p.m. or later, similar to parents' late bedtimes. One-third had difficulty waking up in the morning. There were significant strong positive correlations between some features of restless leg syndrome, daytime tiredness, morning symptoms, and obstructive sleep apnea symptoms. Co-sleeping was prevalent (97.9%). Mean screen time for those who had set time limits was 2.35 ± 1.68 h.

CONCLUSIONS

The English-language translation of the JSQ-P is a questionnaire with good internal consistency that can be used in non-Japanese speaking countries. Parents need to be educated on healthy sleep and screen time practices to optimize children's sleep quality and quantity.

Correlations between sleep disturbance and brain cortical morphometry in healthy children

Background

While the importance of adequate sleep duration to normal brain development is well known, more studies are needed to characterize how undiagnosed sleep disturbance other than suboptimal sleep duration may impact brain development. In this study we aim to understand the relationships between sleep disturbance measures and cortical morphometry in typically-developing children without previous diagnoses of sleep pathology.

Methods

Healthy 8-year-old children (30 boys, 37 girls) without clinical diagnosis of sleep disorders were prospectively recruited for brain MRI and their parents completed the Children’s Sleep Habits Questionnaire (CSHQ). Total sleep disturbance score, as well as 8 subscales including bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, night waking, parasomnias, sleep disordered breathing, and daytime sleepiness were calculated, and their relationships with cortical morphometry features including cortical gray matter volume, cortical thickness, and surface area were investigated, controlled for total cortical volume and sex.

Results

The CSHQ total sleep disturbance score significantly correlated with cortical surface area in a cluster in the left middle temporal gyrus (P < 0.001, R = -0.54). In addition, the bedtime resistance subscale negatively correlated with cortical surface area in a cluster in the right fusiform gyrus (P < 0.001, R = -0.50). No other clusters showed significant relationships between CSHQ total score or subscales and cortical features for this cohort.

Conclusion

Significant relationships between sleep disturbance scores in typically-developing children without clinical diagnosis of sleep pathology and their brain cortical surface area in two temporal lobe regions were identified, suggesting that undiagnosed sleep disturbance may potentially impact brain development even in healthy children.

Association between sleep habits/disorders and emotional/behavioral problems among Japanese children

Actual sleep status and the association between sleep habits/disorders and emotional/behavioral problems among children in the development stage have not been fully clarified. A questionnaire survey was conducted on the sleep habits/disorders (Brief Child Sleep Questionnaire; BCSQ) and emotional/behavioral problems (Strengths and Difficulties Questionnaire; SDQ) of 87,548 children enrolled in ordinary classes in nine grade levels from the first grade of elementary school to the third grade of junior high school from December 2009 to April 2010. As school grade increased, children's bedtimes were delayed and sleep duration was reduced by 2.0 h over the nine grade levels. Based on the BCSQ, 18.3% of children were judged to have some type of sleep disorder, and about 30% to 40% of children had sleep symptoms at bedtime, during sleep, and at wake time. Multiple regression analysis showed that emotional and behavioral problems were associated with presence of any sleep symptom, longer sleep latency, and longer awake time after sleep onset, whereas total sleep time was not. Sleep symptoms at wake time were most strongly associated with emotional and behavioral problems. Status of sleep habits/disorders should be considered when interpreting emotional/behavioral problems in school-age children.

Attention-deficit/hyperactivity disorder symptoms and sleep problems in preschool children: the role of autistic traits

BACKGROUND

Sleep problems are elevated in children with attention-deficit/hyperactivity disorder (ADHD). However, until now there has been comparatively little research on the role of autistic traits in this association. The current study examined the association between ADHD symptoms and sleep problems in Japanese preschool children and whether autistic traits might also be important for this relationship.

METHODS

Data were analyzed from 1053 children (average age 64.14 months, range 58-71; 50.3% male) that were drawn from the Tama Children's Survey (TCS). Parent-reported information was obtained on ADHD symptoms using the Strengths and Difficulties Questionnaire (SDQ) and autistic traits with the Social Responsiveness Scale Second Edition (SRS-2). Parents also provided information on three different categories of sleep problems experienced by their children - parasomnias, sleep disordered breathing and awakening/daytime problems. Ordinal logistic regression analysis was used to examine the associations.

RESULTS

In analyses adjusted for sociodemographic factors, the mother's mental health and child's emotional problems, compared to children with no ADHD symptoms or autistic traits, children with only ADHD symptoms had significantly increased odds for only one of 11 individual sleep problems - waking in a negative mood. In contrast, children with comorbid ADHD symptoms and autistic traits had elevated odds for five sleep problems with odds ratios ranging from 2.10 (takes time to become alert in the morning) to 3.46 (excessive body movement while sleeping).

CONCLUSIONS

Sleep problems may be especially elevated in children with comorbid ADHD symptoms and autistic traits.

The Children's Sleep Habits Questionnaire: Identification of sleep dimensions, normative values, and associations with behavioral problems in Italian preschoolers

OBJECTIVE

To study the use of the Children's Sleep Habits Questionnaire (CSHQ) to evaluate sleep problems dimensions, norm values, and association of sleep problems with behavioral problems in Italian preschoolers.

DESIGN

Sleep dimensions in CSHQ were investigated via parallel and principal component analyses, norm and at-risk values were investigated by exploring the association between CSHQ and the CBCL sleep problems scale, and bivariate associations between CSHQ and internalizing and externalizing behavioral problems were computed.

PARTICIPANTS

A total of 725 mothers of preschool children (mean age = 4.59 years; SD = 0.97 years; range: 3-6 years) from 10 kindergartens in Central Italy.

MEASUREMENTS

CSHQ together with the Child Behavior Checklist 1 ½-5 (CBCL).

RESULTS

The analyses suggested the existence of 7 sleep dimensions, which were meaningfully interpretable. The CSHQ total score had good internal consistency and showed strong associations with the sleep problems scale of the CBCL. Children scoring in the normative range of the CBCL sleep problems scale had a mean value at the CSHQ total score of 47.03 (6.42), children scoring in the borderline and clinical range (4.4%) of 57.13 (5.11). Moderate associations were found between CSHQ total score and internalizing and CBCL externalizing behavioral problems.

CONCLUSIONS

CSHQ values were higher than those reported in other countries and with school-age children, but only a small number of children belonged to the at-risk group based on CBCL norms for the sleep problems scale. CSHQ moderately and comparably correlated with internalizing and externalizing problems. The CSHQ is a meaningful tool for the investigation of sleep problems in Italian preschoolers. Given the heterogeneity of item frequencies at a dimension level, considering scores along items and dimensions might be more informative at a clinical and applied level.

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.

Pediatric Sleep Tools: An Updated Literature Review

Since a thorough review in 2011 by Spruyt, into the integral pitfalls of pediatric questionnaires in sleep, sleep researchers worldwide have further evaluated many existing tools. This systematic review aims to comprehensively evaluate and summarize the tools currently in circulation and provide recommendations for potential evolving avenues of pediatric sleep interest. 144 "tool"-studies (70 tools) have been published aiming at investigating sleep in primarily 6-18 years old per parental report. Although 27 new tools were discovered, most of the studies translated or evaluated the psychometric properties of existing tools. Some form of normative values has been established in 18 studies. More than half of the tools queried general sleep problems. Extra efforts in tool development are still needed for tools that assess children outside the 6-to-12-year-old age range, as well as for tools examining sleep-related aspects beyond sleep problems/disorders. Especially assessing the validity of tools has been pursued vis-à-vis fulfillment of psychometric criteria. While the Spruyt et al. review provided a rigorous step-by-step guide into the development and validation of such tools, a pattern of steps continue to be overlooked. As these instruments are potentially valuable in assisting in the development of a clinical diagnosis into pediatric sleep pathologies, it is required that while they are primary subjective measures, they behave as objective measures. More tools for specific populations (e.g., in terms of ages, developmental disabilities, and sleep pathologies) are still needed.

Prevalence of childhood obstructive sleep apnea syndrome and its role in daytime sleepiness

Objectives

To investigate childhood obstructive sleep apnea syndrome (OSAS) and its role in daytime sleepiness among school-age children.

Methods

A questionnaire survey was conducted with 25,211 children aged 6–15 (mean, 10.39) years attending 148 elementary and 71 middle schools in 10 prefectures across Japan and their parents. Questions concerned 4 sleep habit items (bedtime, sleep onset latency, wake time after sleep onset, wake-up time) and 4 sleep disorder items (loud snoring, snorts/gasps, breathing pauses, seems very sleepy in the daytime). Total sleep time (TST) was calculated with sleep habits. Severe possible OSAS (p-OSAS) was defined as having loud snoring, snorts and gasps, or breathing pauses “frequently” (≥ 5 times per week), and mild p-OSAS was rated as having any of these “sometimes” (2–4 times per week). Severe daytime sleepiness was defined as seeming very sleepy “frequently” and mild daytime sleepiness as seeming very sleepy “sometimes”.

Results

Mean prevalence of mild to severe p-OSAS and severe p-OSAS in children across all grade levels was 9.5% and 1.6%, respectively. p-OSAS was particularly prevalent in children at lower elementary levels, decreasing with advancing grade levels. Prevalence of mild and severe daytime sleepiness was 6.1% and 0.9%, respectively, among all children (7.0%). Prevalence of daytime sleepiness increased with advancing grade levels, particularly in middle-school level. Average TST was 8.4 ± 2.2 h in both elementary and middle-school levels, and decreased as grades advanced, particularly in middle-school levels. Multivariate logistic regression analysis showed that middle-school level, TST < 8 h, and p-OSAS were independent factors for daytime sleepiness. Strong correlations were found between severe daytime sleepiness and severe p-OSAS or TST < 6 h, and between daytime sleepiness and loud snoring or breathing pauses.

Conclusion

p-OSAS may be an independent factor influencing daytime sleepiness in school-age children. Loud snoring and breathing pauses could be clinical markers for children with severe daytime sleepiness.

Association of sleep with emotional and behavioral problems among abused children and adolescents admitted to residential care facilities in Japan

BACKGROUND

The psychological care of abused children in the child protection system is an urgent issue in Japan. Child abuse has a serious impact on children's emotion and behavior, but there is virtually no evidence about how child abuse affects sleep, which is closely related to behavioral and emotional control. In this study, we sought to identify sleep habits and suspected sleep disorders among abused children and adolescents admitted to residential care facilities in Japan and to investigate their association with emotional and behavioral problems.

METHODS

The study targeted 273 abused children and adolescents (age range: 4 to 15 years) who had been admitted to a residential care facility in Japan. They were assessed by physicians and other personnel at facilities with expertise in childcare and abuse. Respondents completed a brief sleep questionnaire on the incidence of problematic sleep habits and suspected sleep disorders as well as a questionnaire on emotional and behavioral issues.

RESULTS

Approximately 40% of the abused children and adolescents had some sleep-related symptoms at bedtime and waking, and 19% had suspected sleep disorder. Abused children with emotional and behavioral problems had a significantly higher incidence of suspected sleep disorders than abused children without such problems, and this incidence was particularly high among those with antisocial behavior and depressive behavior. Our predictive model also showed that antisocial behavior and depressive behavior were significant predictors of suspected sleep disorders.

CONCLUSION

Careful assessment and appropriate therapeutic intervention for sleep disorders are required in abused children and adolescents with emotional and behavioral problems.

Effects of l-Carnosine Supplementation on Sleep Disorders and Disease Severity in Autistic Children: A Randomized, Controlled Clinical Trial

Sleep disorders are frequently reported in autistic patients. Evidences suggest that increased oxidative stress and reduced antioxidants may play a major role in the pathogenesis of these disorders. Carnosine acts as an antioxidant, antitoxic and neuroprotective agent. The aim of this trial study was to examine the effects of carnosine supplementation on the sleep disorders and severity of autism core symptoms in autistic patients. In this double-blind, randomized clinical trial, 43 autistic patients (31 boys and 12 girls; aged 4 to 16 years) were divided into two groups of carnosine and control that received 500 mg of carnosine and 500 mg of placebo per day for 2 months, respectively. Sleep disorders were measured using Children's Sleep Habits Questionnaires. Gilliam Autism Rating Scale 2 was used to assess the effects of carnosine supplementation on the autism severity. Carnosine supplementation did not change anthropometric indices (p > 0.05) and showed no effect on autism severity (p > 0.05), whereas it significantly reduced sleep duration (p = 0.04), parasomnias (p = 0.02) and total sleep disorders score by 7.59% (p = 0.006) when compared with the control group. The results suggest that carnosine supplementation could be effective in improving sleep disturbances, in particular sleep duration and parasomnias subscales.