Children's Sleep Behavior Scale: normative data on 870 children in grades 1 to 6

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

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.

Use and Effectiveness of Sleep Medications by Parent Report in Individuals with Williams Syndrome

OBJECTIVE

Sleep disorders are common in individuals with Williams syndrome (WS), and sleep disturbance has a significant negative effect on attention, learning, and behavior. The use of sleep-inducing medicine in individuals with WS has not been widely investigated. The objective of this study was to evaluate the use and effectiveness of sleep medications among a large sample of individuals with WS by parent survey.

METHODS

A survey of the use and effectiveness of sleep medications was completed by 513 (of 2846) members of the Williams Syndrome Association. The online survey asked for the age at initiation, degree of effectiveness (helpful, somewhat helpful, and not helpful), and side effects.

RESULTS

One hundred thirty participants (25%) indicated that their family member with WS had taken medication to help with sleep. Melatonin was the most commonly reported medication taken for sleep, with 91% of parents reporting that it was "helpful" or "somewhat helpful" for their child with WS. Those who reported taking melatonin reported very few, if any, side effects.

CONCLUSION

This parent-completed survey is a preliminary study showing the positive benefit of melatonin for individuals with WS who have disrupted sleep. The findings support the need for further study of the use of melatonin, in addition to behavioral sleep aids, given evidence that sleep disturbance negatively influences cognition and behavior.

Mother's Work Status on Children's Bruxism in a Subset of Saudi Population

Aims and Objectives:

The aims and objectives of this study were to determine if an association exists between mothers work status and her children's incidence of bruxism and habits related to bruxism.

Materials and Methods:

A cross-sectional study was conducted through data collection of a questionnaire answered by 561 mothers’ about their working status and their child's habits and behaviors. The survey consisted of 5 parts with a total of 34 questions: mother's information, child's behavior, child's sleeping pattern, mother's knowledge about bruxism, and child's medical history. Odds ratios, Chi-square, and their corresponding 95% confidence intervals are reported. Statistical significance was set at P ≤ 0.05.

Results:

The work status of the mother was not statistically significant in increasing the incidence of a child to have bruxism. However, this study clearly elucidates that 7 of the 15 habits correlate significantly with a status of bruxism. According to this sample, a child, that is, reported to be aggressive is more than twice as likely to have nocturnal bruxism. Likewise, any child that bites their nails, complains of headaches, drools in their sleep, snores, complains of muscle cramps, and colic is more than twice as likely to be a nocturnal bruxer than a child that does not have these habits.

Conclusion:

The prevalence of children's bruxism in this convenient sample was 34.5% (n = 141). The concerning habits related to bruxism can serve the pediatric dentist, general dentist, general practitioner, and primary care provider of children having these red flags as indicators of bruxism. It is imperative that parents of these children be made aware these habits that may occur together, alone or even simultaneously with bruxism.

Nightmares affect the experience of sleep quality but not sleep architecture: an ambulatory polysomnographic study

BACKGROUND

Nightmares and bad dreams are common in people with emotional disturbances. For example, nightmares are a core symptom in posttraumatic stress disorder and about 50% of borderline personality disorder patients suffer from frequent nightmares. Independent of mental disorders, nightmares are often associated with sleep problems such as prolonged sleep latencies, poorer sleep quality, and daytime sleepiness. It has not been well documented whether this is reflected in objectively quantifiable physiological indices of sleep quality.

METHODS

Questionnaires regarding subjective sleep quality and ambulatory polysomnographic recordings of objective sleep parameters were collected during three consecutive nights in 17 individuals with frequent nightmares (NM) and 17 healthy control participants (HC).

RESULTS

NM participants reported worse sleep quality, more waking problems and more severe insomnia compared to HC group. However, sleep measures obtained by ambulatory polysomnographic recordings revealed no group differences in (a) overall sleep architecture, (b) sleep cycle duration as well as REM density and REM duration in each cycle and (c) sleep architecture when only nights with nightmares were analyzed.

CONCLUSIONS

Our findings support the observation that nightmares result in significant impairment which is independent from disturbed sleep architecture. Thus, these specific problems require specific attention and appropriate treatment.

The Effectiveness of Emotive Imagery in the Treatment of Darkness Phobia in Children

This study examined the effectiveness of emotive imagery as a treatment for clinically significant darkness phobia in 7- to 10-year-old children. Twenty-four clinically diagnosed children were randomly assigned to either emotive imagery treatment or a waiting-list control condition. Emotive imagery was conducted over six sessions, one per week. The results demonstrated that the emotive imagery group showed significantly greater reductions in darkness fears and anxiety according to child and parent reports and a behavioural darkness probe task, in comparison to the waiting-list group. The waiting-list children showed minimal reductions in fearfulness over the 20-week waiting-list period. The improvements of the emotive imagery group were maintained at the 3-month follow-up.

Associations of sleep disturbance with ADHD: implications for treatment

Attention-deficit/hyperactivity disorder (ADHD) is commonly associated with disordered or disturbed sleep. The relationships of ADHD with sleep problems, psychiatric comorbidities and medications are complex and multidirectional. Evidence from published studies comparing sleep in individuals with ADHD with typically developing controls is most concordant for associations of ADHD with: hypopnea/apnea and peripheral limb movements in sleep or nocturnal motricity in polysomnographic studies; increased sleep onset latency and shorter sleep time in actigraphic studies; and bedtime resistance, difficulty with morning awakenings, sleep onset difficulties, sleep-disordered breathing, night awakenings and daytime sleepiness in subjective studies. ADHD is also frequently coincident with sleep disorders (obstructive sleep apnea, peripheral limb movement disorder, restless legs syndrome and circadian-rhythm sleep disorders). Psychostimulant medications are associated with disrupted or disturbed sleep, but also ‘paradoxically’ calm some patients with ADHD for sleep by alleviating their symptoms. Long-acting formulations may have insufficient duration of action, leading to symptom rebound at bedtime. Current guidelines recommend assessment of sleep disturbance during evaluation of ADHD, and before initiation of pharmacotherapy, with healthy sleep practices the first-line option for addressing sleep problems. This review aims to provide a comprehensive overview of the relationships between ADHD and sleep, and presents a conceptual model of the modes of interaction: ADHD may cause sleep problems as an intrinsic feature of the disorder; sleep problems may cause or mimic ADHD; ADHD and sleep problems may interact, with reciprocal causation and possible involvement of comorbidity; and ADHD and sleep problems may share a common underlying neurological etiology.

Prevalence and correlates of disturbed dreaming in children

Relatively little is known about nightmares and other forms of disturbed dreaming in children. This article reviews the literature on the prevalence and correlates of nightmares in children and highlights key methodological issues in the field. Results show that regardless of how they are defined and measured, nightmares affect a significant proportion of children of all ages and there is some evidence to suggest that nightmare frequency may peak around the age of 10. Gender differences in nightmare frequency, with girls reporting more nightmares than do boys, tend to appear between the ages of 10 and 15. Although nightmares are associated with a range of psychosocial difficulties (e.g., stress, behavioural problems), elevated anxiety and concomitant sleep-related disorders (e.g., sleepwalking) are among the most robust correlates of nightmares. Very few studies have examined nightmare treatment in children, but promising results have been obtained with imagery rehearsal therapy. Overall, research in the field has been hampered by inconsistent definitions for nightmares, by extensive variability in questionnaire items used to measure nightmare frequency, and by a lack of awareness of how using parents versus children as respondents may impact results. Longitudinal studies are needed to better understand how nightmares and their correlates evolve during childhood and adolescence, to delineate their clinical significance, and to develop effective and age-appropriate treatment strategies.

Sleep-laughing--hypnogely

OBJECTIVE

To explain relatively common phenomenon of laughing during sleep and help to better define criteria for differentiating between physiological and pathological sleep-laughing.

METHODS

Observational study of patients who underwent a sleep assessment in a referential tertiary health facility.

RESULTS

A total of ten patients exhibited sleep laughing, nine of whom had episodes associated with rapid eye movement (REM) sleep. Also, in one of the patients sleep-laughing was one of the symptoms of REM sleep Behaviour Disorder, and in another patient sleep-laughing was associated with NREM sleep arousal parasomnia.

CONCLUSION

The collected data and review of literature suggests that hypnogely in majority of the cases presents as a benign physiological phenomenon related to dreaming and REM sleep. Typically, these dreams are odd, bizarre or even unfunny for a person when awake. Nevertheless, they bring a sense of mirth and a genuine behavioural response. In a minority of cases, sleep-laughing appears to be a symptom of neurological disorders affecting the central nervous system. In these patients the behavioural substrate differs when compared to physiological laughing, and the sense of mirth is usually absent.

Psychometric properties of a sleep questionnaire for use in individuals with intellectual disabilities

We examined the psychometric properties of one part of the Sleep Questionnaire developed by Simonds and Parraga (SQ-SP; 1982), a questionnaire that is frequently used to explore sleep problems and behaviors related to sleep in individuals with intellectual disability (ID). The SQ-SP was completed for 345 individuals with ID (sleep clinic n = 146; control group n = 103; published studies n = 68; psychiatric clinic n = 28). Internal consistency was good (Cronbach's α = .80) and test-retest reliability for the total SQ-SP score was also good (Spearman's rank correlation = .83, p<.01). Convergent validity was adequate (r = .79, p<.001) and concurrent validity was satisfactory (r = .52, p<.001). Exploratory factor analysis suggested a 5-factor structure (Snoring, Daytime sleepiness, Complaints related to sleep, Sleep apnea and Anxiety related to sleep). Internal consistency of the five factors ranged from modest (Cronbach's α = .57) to good (Cronbach's α = .82). Confirmatory factor analysis corroborated the 5-factor structure. The Composite Sleep Index, the total SQ-SP score and the factor scores on Daytime Sleepiness and Complaints related to sleep were able to differentiate the control group from the sleep clinic group. The SQ-SP appears to be a reliable and valid tool in assessing sleep and different types of sleep disturbance in individuals with ID.

Nightmare and sleep paralysis among Japanese adolescents: a nationwide representative survey

OBJECTIVE

The objective of this study was to clarify the prevalence of nightmares and sleep paralysis and associated factors among Japanese adolescents.

METHODS

This study was designed as a cross-sectional sampling survey. The targets were junior and senior high schools throughout Japan. Self-reported anonymous questionnaires were sent to schools for all students to complete.

RESULTS

A total of 90,081 questionnaires were analyzed. The overall response rate was 62.6%, and the prevalence of nightmares and sleep paralysis was 35.2% and 8.3%, respectively. Multiple logistic analyses revealed that female sex, drinking alcohol, poor mental health, difficulty initiating sleep, low subjective sleep assessment, presence of excessive daytime sleepiness, and presence of sleep paralysis had higher odds ratios than others for nightmares. Male sex, poor mental health, drinking alcohol, taking a long daytime nap, early or late bedtime, difficulty initiating sleep, low subjective sleep assessment, presence of excessive daytime sleepiness, and presence of nightmares had higher odds ratios than other factors for sleep paralysis.

CONCLUSIONS

This study has revealed the prevalence of nightmares and sleep paralysis among Japanese adolescents. Furthermore, the results of this study suggest that it is important to maintain regular sleep habits for preventing these symptoms. We propose that health education about regular sleep habits should be promoted among Japanese adolescents.

Pediatric sleep questionnaires as diagnostic or epidemiological tools: a review of currently available instruments

An extensive list of published and unpublished instruments used to investigate or evaluate sleep issues in children was collected and assessed based on the fundamental operational principles of instrument development (11 steps). Of all the available tools identified, only a few were validated and standardized using appropriate psychometric criteria. In fact, only 2 fulfill all desirable criteria and approximately 11 instruments seem to adhere to most of the psychometric tool development requirements, and were therefore assessed in greater detail. Notwithstanding, in the rapidly developing scientific world of pediatric sleep, there are too many tools being used that have not undergone careful and methodical psychometric evaluation, and as such may be fraught with biased or invalid findings. It is hoped that this initial effort in categorizing and assessing available tools for pediatric sleep will serve as recognition of the relatively early developmental stage of our field, and provide the necessary impetus for future tool development using multicentered approaches and adequate methodologies.

Nightmares associated with the eveningness chronotype

Relations between common nightmares and chronobiological factors remain poorly understood. The possibility that nightmare frequency and distress are associated with chronotype ("morningness-eveningness") was investigated in a sample of respondents to an Internet questionnaire. Over a 4(1/2)-year period, a total of 3978 subjects (mean age = 26.5 +/- 11.6 yrs; age range = 10-69; 2933 female, 1045 male) submitted responses to single items about chronotype and nightmares as well as to other demographic variables. Analyses of chronotype and nightmares items by age and gender replicated most previous findings for these measures-validating their further assessment-and uncovered abrupt increases in nightmare distress between ages 10-19 and 20-29 for females and ages 30-39 and 40-49 for males. Most important, there was a strong association between nightmares and eveningness for female subjects. The latter was expressed as a linear association between nightmare frequency and increasing eveningness and a cubic association between nightmare distress and increasing eveningness; the definite evening types displayed the most severe nightmares. The effect for nightmare frequency was independent of age and sleep duration but was eliminated when nightmare distress was covaried. For females, the nightmare/eveningness association appeared at ages 20 to 29 for the definite evening type and only later, at ages 30 to 39, for the moderate evening type. Findings are consistent with the possibility that nightmares are the expression of a more general pathological factor that is characteristic of eveningness and that is responsible for affective symptoms such as neuroticism and depression. This pathological factor appears to be expressed in late adolescence/ early adulthood, and relative morningness may be a protective factor delaying its onset. The well-established circadian modulations of cognitive, social, and affective tasks that are influenced by chronotype may extend to the memory and affective processes of sleep-including dreaming. This chronotypic influence, together with a likely gender difference in the neurophysiological substrate of emotional processing, may result in the differential occurrence of nightmares for female evening types.

Parental rating of sleep in children with attention deficit/hyperactivity disorder

OBJECTIVE

Sleep problems have often been associated with attention deficit/hyperactivity disorder (ADHD). Parents of those with ADHD and children with ADHD report sleep difficulties more frequently than healthy children and their parents. The primary objective of this paper is to describe sleep patterns and problems of 5 to 11-year-old children suffering from ADHD as described by parental reports and sleep questionnaires.

METHOD

The study included 321 children aged 5-11 years (average age 8.4 years); 45 were diagnosed with ADHD, 64 had other psychiatric diagnoses, and 212 were healthy. One hundred and ninety-six of the test subjects were boys and 125 were girls. A semi-structured interview (Kiddie-SADS-PL) was used to DSM-IV diagnose ADHD and comorbidity in the clinical group. Sleep difficulties were rated using a structured sleep questionnaire (Children Sleep Behaviour Scale).

RESULTS

Children diagnosed with ADHD had a significantly increased occurrence of sleep problems. Difficulties relating to bedtime and unsettled sleep were significantly more frequent in the ADHD group than in the other groups. Children with ADHD showed prolonged sleep onset latency, but no difference was shown regarding numbers of awakenings per night and total sleep time per night. Comorbid oppositional defiant disorder appeared not to have an added effect on problematic behaviour around bedtime.

CONCLUSION

Parents of children with ADHD report that their children do not sleep properly more often than other parents. The ADHD group report problems with bedtime resistance, problems with sleep onset latency, unsettled sleep and nightmares more often than the control groups. It may therefore be relevant for clinicians to initiate a closer examination of those cases reporting sleep difficulties.

Sleep terrors in children: a prospective study of twins

OBJECTIVE

There is growing evidence that genetic factors are involved in the occurrence of sleep terrors. Twin studies provide invaluable information regarding genetic and environmental factors that can affect the manifestation of the disease; however, most previous twin studies on sleep terrors were performed retrospectively or with a sample that was too small to yield conclusive results. The aim of this large prospective study was to clarify the genetic and environmental contributions to sleep terrors in childhood.

METHODS

In all, 390 pairs of monozygotic and dizygotic twins were recruited at birth for a longitudinal study. The prevalence and frequency of sleep terrors were assessed at 18 and 30 months of age with a questionnaire administered to the biological mother of the twins. Zygosity was determined by a questionnaire and genotyping. The prevalence and polychoric correlation for each type of twins were calculated. Structural-equation modeling was used to determine the proportion of variance attributable to additive genetic, shared, and nonshared environmental factors.

RESULTS

The prevalence of sleep terrors was 36.9% at 18 months and 19.7% at 30 months; 49% of affected children were boys, and 51% were girls. At 18 months, the polychoric correlations were 0.63 for monozygotic and 0.36 for the dizygotic twins. These were 0.68 (monozygotic) and 0.24 (dizygotic) at 30 months. Our model-fitting analysis showed that sleep terrors were explained by a 2-component model at 18 months (43.7% additive genetic effects and 56.3% nonshared environment) and at 30 months (41.5% additive genetic effects and 58.5% nonshared environment).

CONCLUSIONS

These results strongly support the heritability of sleep terrors. There also seems to be continuity in genetic effects with the persistence of sleep-terror symptoms.

Nightmares: A new neurocognitive model

Nightmares are a prevalent parasomnia associated with a range of psychiatric conditions and pathological symptoms. Current knowledge about how nightmares are produced is still influenced by neo-psychoanalytic speculations as well as by more recent personality, evolutionary and neurobiological models. A majority of these models stipulate some type of emotionally adaptive function for dreaming, e.g., image contextualization, affect desomatization, mood regulation or fear extinction. Nightmares are widely seen to be either an intensified expression of an emotionally adaptive function or, conversely, as evidence of its breakdown. Our recent, affective network dysfunction (AND) model, integrates the tenets of many prior models in proposing that nightmares reflect problems with the fear extinction function of dreaming. This new model accounts for a wide range of dysphoric dream imagery (bad dreams, idiopathic nightmares, post-traumatic nightmares) and incorporates recent findings in the areas of brain imaging, sleep physiology, PTSD, anxiety disorders and the consolidation and extinction of fear memories.

Dyssomnias and parasomnias in early childhood

OBJECTIVES

Our aim for this study was to determine the prevalence of dyssomnias and various parasomnias in early childhood and to describe their temporal evolution, gender differences, and correlates.

METHODS

This research is part of a longitudinal study of child development. A randomized, 3-level, stratified survey design was used to study a representative sample of infants who were born in 1997-1998 in the province of Quebec (Canada). When the children were 2.5 years of age, 1997 families agreed to be interviewed. The presence of dyssomnias or parasomnias was obtained from a self-administered questionnaire that was completed by the mother at each round of measures.

RESULTS

The percentage of children with frequent night wakings decreased steadily from 36.3% at age 2.5 to 13.2% at age 6. Similarly, the percentage of children who had difficulty falling asleep at night decreased significantly from 16.0% at ages 3.5 and 4 to 10% at age 5 and to 7.4% at age 6. The overall prevalence of each parasomnia for the period studied was as follows: somnambulism, 14.5%; sleep terrors, 39.8%; somniloquy, 84.4%; enuresis, 25.0%; bruxism, 45.6%; and rhythmic movements, 9.2%. Persistent somnambulism at age 6 was significantly correlated with sleep terrors and somniloquy. Persistent sleep terrors at age 6 were also correlated with somniloquy. Finally, persistent sleep terrors at age 6 were correlated with frequent night wakings. Separation anxiety was associated with persistent night wakings and with somnambulism, bruxism, sleep terrors, and somniloquy.

CONCLUSIONS

There is a high prevalence of night wakings and sleep-onset difficulties in preschool children. Parasomnias are highly prevalent in early childhood and are associated with separation anxiety. However, they have little impact on sleep duration.

Prevalence of sleep problems and their association with inattention/hyperactivity among children aged 6?15 in Taiwan

This study investigated the 6-month prevalence rates of sleep-related problems and their association with daytime inadvertent napping, inattention, hyperactivity/impulsivity, and oppositional symptoms in children and adolescents. A representative school-based sample of 2463 first to ninth graders was recruited using a multistage sampling method. The instruments included the Sleep Habits Questionnaire (including dyssomnia, parasomnia, sleep schedules, and sleep-disordered breathing), the Chinese Health Questionnaire, and the Chinese versions of the Conners' Parent and Teacher Rating Scales-Revised: Short forms. The informants were mothers and teachers. The linear and nonlinear mixed models were used for statistical analyses and sex and age were controlled in the model. Results showed that the rates of middle insomnia, disturbed circadian rhythm, mouth breathing, and daytime inadvertent napping increased with age; whereas those of bedwetting, bruxism, sleep terrors decreased with age. Dyssomnia, sleep-disordered breathing problems, daytime inadvertent napping, and sleep schedules were related to attention-deficit/hyperactivity disorder (ADHD)-related symptoms as assessed by mothers' and teachers' ratings. Parasomnia was associated with ADHD-related symptoms as assessed by mothers' ratings. Our findings suggest an age trend of sleep problems similar to those found in the literature and the association of daytime inadvertent napping, inattention, hyperactivity/impulsivity, and oppositional symptoms with sleep-related problems.

Prevalence of sleep problems and habits in a sample of Saudi primary school children

BACKGROUND

Sleep problems in children vary not only with age, but also with ethnic and sociocultural background. No research has been conducted to assess sleep problems in Saudi elementary school children. This study surveyed parents (or guardians) abouttheir elementary school children's sleep to assess the prevalence of certain sleep problems.

METHODS

The study population comprised boys and girls attending regular public elementary schools in all grades and was conducted during springtime of the year 1999. A questionnaire inquiring about demographic data, specific sleep problems and habits and home environment was distributed and completed bythe parents or guardians.

RESULTS

A total of 1012 complete questionnaires were included in the analysis. The sample comprised 511 boys (50.5%) and 501 girls (49.5%). The mean age was 9.5+/-1.9 years, ranging from 5 to 13 years. Daytime fatigue was the most prevalent sleep problem (37.5%) followed by bedtime resistance (26.2%), difficulty rising in the morning during weekdays (20.7%), and sleep-onset delay (11.8%). Cosleeping with parents was reported in 12.4% of children. The study revealed some differences between boys and girls. Napping during the daytime was reported in 40.8% of children.

CONCLUSION

The study showed that sleep problems are prevalent among Saudi elementary school children. Moreover, the study shed some light on sleep habits and practices in this age group in Saudi Arabia, like the high prevalence of daytime napping.

Odds, prevalence and predictors of sleep problems in school-age normal children

The objectives of the study were to describe the prevalence, odds, and predictors of 36 paediatric sleep behaviours and describe their coexistence in a school-age normal population. The design was community-based questionnaire survey of sleep-wake patterns, sleep environment, and 36 sleep behaviours indicative of six sleep disorder-subscales using the Health-Behaviour Questionnaire. A caregivers' report of 3045 children aged 6-13 years in Belgium constituted the participants. Prevalence of each sleep behaviour was calculated. Log-linear modelling within and between the sleep disorder-subscales was used to screen for coexistence. The effect size of selected night-time parameters to the likelihood of sleep behaviours and disorder-subscale was expressed as odds ratios via logit regression analysis. Significant differences in sleep-wake patterns were found between weekday and weekend. Ranking by odds showed that: (1) sleep problems such as 'tired when waking up', 'repetitive limb movements', 'going to bed reluctantly', and 'sleep paralysis' and; (2) the disorder-subscale 'excessive somnolence' are common in children. Coexistences within and between disorder-subscales of sleep problems are evident in a school-age, normal population. These results suggest that disorders of excessive somnolence (DES) are highly prevalent in a non-clinical sample of school-age children. Furthermore, sleep-onset latency and a noisy, not well-darkened room are predictive towards the odds for exhibiting sleep problems and disorders. It is advocated that more information on the importance of good sleep-wake hygiene should reach parents and children.

Parental perception of sleep problems in children of normal intelligence with pervasive developmental disorders: prevalence, severity, and pattern

OBJECTIVE

This study compares parents' perceptions of the prevalence, severity, and pattern of sleep problems in children of normal intelligence with pervasive developmental disorders (PDDs) with a normative comparison group of children.

METHOD

A survey including the Children's Sleep Habits Questionnaire was mailed to a sample of parents of children (age range 5-12 years) with PDDs (diagnosed by the Autism Diagnostic Interview-Revised) obtained by chart review of the past 7 years and to parents of comparison children matched on age, gender, and postal code.

RESULTS

The response rate in the PDD group was 82.2% (37/45) and 55.8% (43/77) in the comparison group. By individually matching, 23 pairs were obtained. The prevalence of sleep problems in the PDD group was reported by parents as being significantly higher than in the comparison group (78% and 26%, respectively; p < .002), as was the severity (mean score 48.2 and 39.0, respectively; p < .001). Values for four of eight sleep subscales including sleep onset delay, sleep duration, sleep anxiety, and parasomnias were significantly higher in the PDD group.

CONCLUSIONS

Parents report that sleep problems are significantly more prevalent and severe in children of normal intelligence with PDDs compared with normally developing children, and the pattern appears diverse. Sleep problems in children with PDDs require further research and clinical attention.

Development of parasomnias from childhood to early adolescence

OBJECTIVES

This study examines the prevalence and developmental changes of parasomnias and assesses gender differences, relationships between parasomnias, and associations with anxiety and family adversity using data collected during the course of a longitudinal study of a representative sample of children from Québec.

METHOD

The present analyses are based on results available for 664 boys and 689 girls for whom mothers have completed questions concerning demographics, parasomnias, and anxiety level. For the prevalence and developmental aspects of parasomnias, prospective data were collected at annual intervals from 11 to 13 years old and retrospective data for the period between ages 3 and 10 years were collected when the children were 10 years old.

RESULTS

Somniloquy, leg restlessness, and sleep bruxism are the most frequent parasomnias. More girls were afflicted with leg restlessness, while enuresis and somniloquy were more common in boys. High anxiety scores were found in children suffering from night terrors, somniloquy, leg restlessness, sleep bruxism, and body rocking. Parasomnias were unrelated to the index of family adversity.

CONCLUSIONS

Although sleepwalking, night terrors, enuresis, and body rocking dramatically decreased during childhood, somniloquy, leg restlessness, and sleep bruxism were still highly prevalent at age 13 years, paralleling results found in adults. Sleepwalking, night terrors, and somniloquy are conditions often found together. The only robust gender difference was for enuresis. High anxiety scores in parasomnias are reported for the first time in a large, controlled study. Sociodemographic variables do not seem to play a major role in the occurrence of parasomnias.

Sleep and behaviour disturbance in Prader-Willi syndrome: a questionnaire study

The present authors describe sleep problems, including sleep apnoea and excessive daytime sleepiness (EDS), in subjects with Prader-Willi syndrome (PWS). The present paper reports a questionnaire study regarding sleep and behaviour in a group of 29 subjects with PWS, compared with an age- and gender-matched control group. Those with PWS suffered from sleep problems more frequently than the control subjects. Problems included EDS, snoring and early waking. Sleep problems in PWS were not associated with body mass index or weight. Excessive daytime sleepiness was a distinctive feature of the group with PWS, and behavioural disturbance in PWS children and adolescents was associated with EDS. Excessive daytime sleepiness seems to be characteristic of PWS, and may be related to problems with the sleep-wake cycle and hypothalamic dysfunction.

Sleep and daytime behavior in children with obstructive sleep apnea and behavioral sleep disorders

OBJECTIVE

The purpose of this study was: 1) to examine both bedtime sleep behaviors and daytime behaviors associated with daytime sleepiness in a group of children with a primary medical sleep disorder (obstructive sleep apnea syndrome [OSAS]) compared with a group of children with a primary behavioral sleep disorder (BSD) (limit setting sleep disorder or sleep onset association disorder); and 2) to investigate the impact of a comorbid BSD on sleep and daytime behavioral consequences of OSAS.

METHODS

Children referred to a pediatric sleep disorders clinic during a 3-year period with a primary diagnosis of either polysomnographically-confirmed OSAS (n = 100) or a BSD (n = 52) were compared on several parent report measures assessing the following domains: symptoms of sleep disordered breathing, other sleep behaviors (primarily parasomnias), bedtime behaviors, and externalizing daytime behavior problems. The OSAS sample was then divided into a pure OSAS group (n = 78) and an OSAS plus a behavioral sleep diagnosis group (n = 22) based on the presence or absence of delayed sleep onset and/or prolonged nightwakings and compared on the parent-report symptom domains.

RESULTS

Almost one-quarter of the OSAS group had clinically significant behavioral sleep problems, primarily bedtime resistance, in addition to OSAS. Bedtime resistance was associated with a significantly shortened sleep duration in both the BSD and OSAS-BSD groups. Although the OSAS-BSD group had less severe disease, as defined by polysomnographic variables, than the pure OSAS group, they were rated by their parents as having more daytime externalizing behavior problems associated with daytime sleepiness.

CONCLUSIONS

The results of this study suggest that evaluation for comorbid BSD should be done in all children presenting with symptoms of OSAS. The coexistence of such BSDs may contribute significantly to sleep deprivation, and thus to behavioral manifestations of daytime sleepiness in these children.

Prevalence of sleep disorders in childhood and adolescence with headache: a case-control study

Although a relationship between headache and sleep disturbances has been reported in adults, only few data have been available in children. Accordingly, we performed a survey to determine the prevalence of sleep disturbances in children with migraine and tension-type headache. A questionnaire of history and clinical data and of sleep disturbances was given to parents of 283 headache subjects (164 with migraine and 119 with tension-type headache). Results were compared to a normative group comparable for age and sex of 893 normal healthy subjects. Migraine subjects showed a higher prevalence of sleep disturbances during infancy as well as 3-month colic. In both headache groups, more parents had sleep disturbances and there was a higher occurrence of co-sleeping and napping. A high frequency of sleep disturbances involving sleep quality, night awakenings, nocturnal symptoms and daytime sleepiness was reported in headache children. No statistical differences were found in the prevalence of sleep disturbances between migraine and tension-type headache. However, the migraine group tended to have "disturbed sleep" more often with increased prevalence of nocturnal symptoms such as sleep breathing disorders and parasomnias. Our results give further support to an association between sleep and migraine that may have a common intrinsic origin.

The Sleep Disturbance Scale for Children (SDSC). Construction and validation of an instrument to evaluate sleep disturbances in childhood and adolescence

To attempt a categorization of sleep disorders in children, we developed a 27 item Likert-type rating scale (Sleep Disturbance Scale for Children: SDSC) and assessed the psychometric properties was developed. The scale was distributed to the mothers of 1304 children (1157 controls, mean age 9.8 y; 147 sleep disorder subjects, mean age 9.2y, composed of four clinical groups: Insomnia 39 subjects, Hypersomnia 12 subjects, Respiratory disturbances during sleep 25 subjects and Parasomnias 71 subjects). The internal consistency was high in controls (0.79) and remained at a satisfactory level in sleep disorder subjects (0.71); the test/retest reliability was adequate for the total (r = 0.71) and single item scores. The factor analysis (variance explained 44.21%) yielded six factors which represented the most common areas of sleep disorders in childhood and adolescence. Enuresis was the only item with a factor loading lower than 0.40 and with a low inter-item correlation and was therefore eliminated, resulting in a final scale of 26 items. The re-evaluation of the sample, using the factor scores, supported the validity and the discriminating capacity of the scales between controls and the four clinical groups. The correlation between factor scores corroborated the hypothesis that childhood sleep disturbances are not independent entities nor do they cluster into different groupings related to each other. The SDSC appears to be a useful tool in evaluating the sleep disturbances of school-age children in clinical and non-clinical populations.

Sleep habits and disorders in Finnish schoolchildren

A variety of epidemiological sleep parameters was evaluated in 574 Finnish schoolchildren (age 7 to 17 years) and in their parents (454 mothers and 390 fathers). Three questionnaire forms were set, one for the pupil and two for his/her parents including information of sleep habits, disorders, and social background of the pupil and his/her family. The pupils were grouped by age (two preadolescent groups: 7.1-9.3 y and 9.4-13 y, adolescents 13.1-17.1 y) and sex. It was found that bedtime was more often after 22.00 hours among adolescents than preadolescents both at weekends and on weekdays. At weekends the wake-up time was later in adolescents than preadolescents but on weekdays it was opposite in boys. On weekdays girls went earlier to bed than boys and woke up earlier than boys. Total sleep durations both on weekdays and at weekends were longer in preadolescent than in adolescent groups, and longer during weekend nights than on weekday nights in all groups. Girls experienced more dreaming and night waking, but boys snored more. Daytime sleepiness patterns were more common in adolescents than in preadolescents. Children who experienced daytime sleepiness more often had fathers with daily sleep urges. An association was found between age and sleep habits and some daytime sleepiness patterns; adolescents went to bed later and slept less, and had more problems with alertness during daytime than preadolescents. Some differences were also found between boys and girls. The daytime sleepiness of pupils correlated with the same symptom in fathers.

The sleep/wake rhythm in children with autism

The sleep patterns of two groups of children with autism, one with moderate to severe intellectual handicap, and one with mild handicap to normal IQ level, were compared with those of children without autism. Parents completed 14 day sleep diaries and questionnaires. Results suggested that at some stage during childhood, particularly under 8 years of age, the majority of children with autism will experience sleep problems. These problems are likely to be severe in many cases and will generally include one or more of: extreme sleep latencies; lengthy periods of night waking, shortened night sleep; and early morning waking. Such problems may have some specificity for autism as they appear to be rare in non-handicapped children and in children with mild degrees of intellectual handicap. It is likely that sleep problems in early childhood are related to the severe social difficulties present in autism and the consequent inability of these children to use social cues to synchronize their sleep/wake cycle. Continued sleep difficulties at older ages and with higher IQ may also be related to arousal and anxiety factors.

Parents' and children's ratings of sleep behavior, excitement, and tiredness: a 10-week longitudinal study

In a 10-week longitudinal study, 29 parents and their children kept daily records of the children's sleep behaviors, excitement levels, and tiredness levels. Although the hypothesized increase in sleep behaviors such as sleepwalking and restlessness during the week of Christmas did not occur, children rated as more excitable by their parents and themselves exhibited a higher frequency of sleep behaviors. Positive associations were also found between averaged tiredness ratings and sleep scores. The results support previous findings of an association between arousal characteristics of children and their sleep behavior. Moderate validity coefficients were obtained for parents' and children's ratings of excitement, tiredness, and nocturnal waking.

Sleep problems in childhood

Sleep, like eating and toileting, is an individual physical requirement that changes with time as the child matures. Although much about a child's sleep is biologically determined, extrinsic factors, usually through the parents, also mold the child's sleep behavior. Normal sleep for a child is restful to the child and not excessively disruptive to others. Sleep problems interfere with the quality of the child's sleep and frustrate or frighten caretakers. Several sleep problems have their origins in normal sleep behavior from an earlier age. Some, the parasomnias, are caused by self-limited biologic diatheses. Many sleep problems have psychosocial triggers. Sleep disorders only rarely are a primary medical problem that is adequately treated with medication (e.g., narcolepsy). Good history-taking, often accompanied by diary-keeping, will usually identify the problem--the first step in effective treatment. Treatment of a sleep disorder in the pediatrician's office can start with educating caretakers about normative sleep for the age of the child and providing information regarding the cause and natural course of the problem. Treatment also may involve behavioral or psychological intervention or both, but medication is generally not indicated. When needed for short-term treatment, mild sedatives such as antihistamines are used most often. More serious sleep or behavioral problems should be acknowledged by the primary care pediatrician, followed by referral to an appropriate specialist. Inquiry into a child's sleep habits at each well-child visit, coupled with appropriate anticipatory guidance, could make an important contribution to the child and family by preventing problems with sleep and identifying sleep problems early in their evolution. Pediatricians and parents can work together to help children develop good sleep habits that fulfill the child's evolving sleep requirements within the context of the family's needs and expectations.

Nightmares, life events and behaviour problems in preschool children

A postal survey was carried out to identify nursery school children with frequent nightmares in an English city. Of the 22 children reported as suffering from frequent nightmares, 14 came from families who were willing to be interviewed further. A control group with no nightmares, matched for age and sex, was selected from the returns. The mothers of the children in the two groups were interviewed using the Preschool Behaviour Checklist and a life events scale. The results showed that neither life events nor behaviour problems were more prevalent in the frequent nightmares group.

Do diagnostic patterns exist in the sleep behaviors of normal children?

We investigated the factor structure of the Children's Sleep Behavior Scale in an unselected sample of children (N = 838), ages 6 to 12.5 years, drawn from an elementary school population. Although no factor emerged that corresponded exactly to the parasomnias, as described by the Association of Sleep Disorders Centers (1979), all of the variables that loaded on Factor 1 were behaviors characteristic of the parasomnias, with the exception of recalled nightmares. Variables that were expected to load on this factor, but did not, were sleeptalking, teeth grinding, and enuresis. Enuresis was not related to any of the sleep behaviors assessed, and teeth grinding shared less than 9% of the variance with any of the other variables. Many of the variables loaded on more than one factor. The second factor, which was labeled bedtime resistance, was the only clearly unambiguous factor. Of the five factors that emerged, the third reflected positive affect, the fourth was a motor factor, and the fifth was an anxiety factor. Nightmares loaded on the anxiety factor as well as the first factor. The results of the study offered no support for the category of Disorders of Initiating and Maintaining sleep (DIMS), which has a childhood onset.