Child Psychiatry Hum Dev DOI 10.1007/s10578-014-0505-z
ORIGINAL ARTICLE
Sleep Onset and Night Waking Insomnias in Preschoolers with Psychiatric Disorders John R. Boekamp • Lauren R. Williamson Sarah E. Martin • Heather L. Hunter • Thomas F. Anders
•
Ó Springer Science+Business Media New York 2014
Abstract This study examined the nature and prevalence of diagnostically defined sleep disorders, including Sleep Onset Insomnia (SOI) and Night Waking Insomnia (NWI), in a sample of 183 young children admitted to an early childhood psychiatric day treatment program. A semistructured diagnostic interview, the Diagnostic Infant and Preschool Assessment, was used to assess for sleep and other psychiatric disorders. Daily sleep diaries and the Child Behavior Checklist were also examined. 41 % of children met criteria for a sleep disorder; 23 % met diagnostic criteria for SOI and 4 % met criteria for NWI, with an additional 14 % meeting criteria for both (SOI ? NWI). Sleep-disordered children demonstrated longer latency to sleep onset, longer and more frequent night awakenings, less total sleep, and lower sleep efficiency than non-sleep disordered participants. Diagnosable sleep disorders, particularly SOI, were quite common in this acute clinical sample, exceeding previous estimates obtained in community and pediatric practice samples.
J. R. Boekamp H. L. Hunter T. F. Anders Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA J. R. Boekamp (&) Bradley Hospital, 1011 Veterans Memorial Parkway, East Providence, RI 02915, USA e-mail: [email protected] L. R. Williamson S. E. Martin H. L. Hunter Bradley Hospital, East Providence, RI, USA S. E. Martin Department of Psychology, Simmons College, Boston, MA, USA
Keywords Preschoolers Sleep disorders Sleep diaries Psychopathology Diagnostic interview
Introduction The most common sleep difficulties reported for toddlers and preschoolers in Western cultures are problems of going to bed, falling asleep and frequent night awakenings; collectively these problems are referred to as behavioral insomnias of childhood [1–3]. Prevalence estimates for behavioral insomnias are up to 30 % in typically developing preschool age children and are even higher in those with neurodevelopmental impairments, such as autism, learning disorders and intellectual disability [4–11]. In addition, sleep problems in young children frequently cooccur with other behavioral problems, with evidence that inadequate sleep is associated with daytime sleepiness [12], less optimal preschool adjustment [13], and problems of irritability, hyperactivity and attention [4, 14–16]. Moreover, it is likely that the links between early childhood psychiatric symptoms and sleep disturbance are bi-directional and mutually exacerbating [17]. That is, early sleep problems may be both a cause and consequence of cooccurring difficulties with behavioral and emotional selfregulation, with sleep disruption affecting psychiatric symptoms and psychiatric symptoms affecting sleep–wake organization. To date, most research examining the links between early childhood sleep and behavioral problems has focused on typically developing young children, based on samples drawn from the community and general pediatric practices [13, 18, 19]. In contrast, there has been relatively less attention devoted to understanding the nature and prevalence of sleep problems in young children presenting with
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Child Psychiatry Hum Dev Fig. 1 RDC criteria for Sleep Onset Insomnia and Night Waking Insomnia in toddlers and preschoolers. Sleep onset and Night Waking Insomnias are not diagnosed before 1 year of age. The criteria pertain to solitary sleeping toddlers and preschoolers. a5–7 episodes/ week for at least 1 month are most likely continuous and require intervention. bReunions reflect resistances in going to bed (e.g., repeated bids, protests, struggles). c Awakenings usually require parental intervention and occur after the child has been asleep for [10 min
SLEEP ONSET INSOMNIA A. Symptoms present for at least four weeks and involve 5 – 7 episodes per weeka B. Significant difficulty falling asleep Suggested cut-offs for duration and severity (any two of three criteria listed): 12-24 months of age:
(1) > 30 minutes to fall asleep (2) parent remains in room for sleep onset (3) 3 or more reunionsb
> 24 months of age:
(1) > 20 minutes to fall asleep (2) parent remains in room for sleep onset (3) 2 or more reunionsb
NIGHT WAKING INSOMNIA A. Symptoms present for at least four weeks and involve 5 – 7 episodes per week a B. Significant difficulty staying asleep Suggested cut-offs for duration and severity: c
12-24 months of age:
3 or more awakenings > 30 minutes
24-36 months of age:
1 or more awakenings > 20 minutes
>36 months of age:
1 or more awakenings > 10 minutes
c
clinically significant diagnosed psychiatric disorders, despite compelling evidence for elevated rates of sleep problems in older children and adolescents with specific DSM-IV psychiatric disorders. For example, two extensive recent reviews suggest that, in school-aged children and adolescents, psychiatric disorders and sleep disorders are highly co-morbid [20, 21]. The lack of research on sleep in preschool age children with psychiatric disorders represents a significant gap in the early childhood mental health literature, particularly given increasing awareness of the prevalence and seriousness of mental health problems in early childhood [22, 23]. In addition, it is important that research on sleep disruption in young children with emotional and behavioral problems include attention to diagnostically defined sleep disorders. This perspective is well articulated by Steinsbekk, Berg-Nielsen, and Wichstrom (2013), who noted that symptoms of sleep problems may not translate directly into specific sleep disorders. These researchers examined the prevalence of diagnosed sleep disorders (including insomnia, hypersomnia, nightmare disorder, and sleepwalking disorder) in a large, screen-stratified sample of Norwegian preschoolers and found that such disorders were relatively common and were frequently associated with other DSM-IV diagnoses, particularly anxiety disorders [19]. Such findings further underscore the importance
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c
of examining sleep problems in preschoolers presenting with clinically significant emotional and behavioral impairments and to do so using diagnostically defined sleep disorder criteria. The International Classification of Sleep Disorders Diagnostic and Coding Manual, 2nd Edition (ICSDDCM2) [24] sub classifies the behavioral insomnias into a number of sub-categories including Limit-Setting Sleep Disorder and Sleep-Onset Association Disorder. The former is characterized by ‘‘the inadequate enforcement of bedtimes by a caretaker with resultant stalling or refusal to go to bed at an appropriate time,’’ and is used to define falling asleep problems. The latter occur ‘‘when sleep onset is impaired by the absence of a certain object or set of circumstances,’’ and is used for middle-of-the-night awakening problems. Both of the disorders are further defined by duration (acute, sub-acute, chronic) and severity criteria (mild, moderate, severe). Anders and Dahl [2] proposed research diagnostic criteria (RDC) for these two diagnostic subtypes: Sleep Onset Insomnia (SOI) and Night Waking Insomnia (NWI), suggesting more quantitative and developmentally sensitive duration and severity criteria and de-emphasizing the etiologic roles of learning and conditioning as criterion for diagnosis (Fig. 1). The RDC sleep disorder criteria proposed by Anders and Dahl have been incorporated into the recently developed
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Diagnostic Infant and Preschool Assessment [25], a semistructured diagnostic interview for the clinical assessment of very young children. The availability of this and similar interview-based tools that include modules for the diagnosis of early childhood sleep disorders [26] is of importance to practicing clinicians, given that other sleep assessment techniques may be time-consuming (e.g., lengthy questionnaires, sleep diaries) or require specialized technology or training (e.g., actigraphy, polysomnography), and as such, are unlikely to be feasible in a busy clinical practice, particularly when sleep is not the presenting complaint. On the other hand, brief rating scales and scales that assess only general aspects of sleep disruption have been criticized for lack of diagnostic specificity [27]. Yet despite the availability and potential clinical advantages of diagnostic interviews that include modules for the assessment of early sleep disorders, only a few studies have empirically examined the use of these modules [12, 19] and we are aware of none that have done so in a preschool psychiatric sample. The primary goal of this study was to examine the prevalence of SOI and NWI, based on RDC and as assessed using the Diagnostic Infant and Preschool Assessment (DIPA), in a sample of very young children attending an intensive psychiatric day treatment program. In addition, we examined the associations between sleep insomnias and other DIPA-diagnosed psychiatric disorders, including Oppositional Defiant Disorder (ODD), Attention-Deficit/ Hyperactivity Disorder (ADHD), Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), Separation Anxiety Disorder (SAD), and Social Phobia. Given that the original validation study for the DIPA [25] did not present data on the DIPA sleep disorders module, an additional aim of the present study was to examine the concurrent criterion validity of DIPA-derived SOI and NWI diagnoses, as compared to daily sleep diaries and the sleep problems scale of the Child Behavior Checklist [28].
Methods Participants Participants were 183 children (ages 19–71 months, M = 50.4 months, SD = 12.5 months) who presented to a hospital-based day treatment program for young children with severe emotional and behavioral problems. A parent or guardian provided informed consent for child and family participation in the study. Participating parents were, on average, 31 years of age and most (89 %) were the biological mother of the participating child. Additional criteria for inclusion in this study included: (a) the participating child was under 6 years of age, (b) the family was
Table 1 Demographic and clinical characteristics of the sample Demographic characteristics Gender of child
73.2 % male
Age of child
M = 50.4 months (SD = 12.5)
Child ethnicity (%)
White/Non-hispanic = 54 % Black/African-American = 18 % Hispanic/Latino = 15 % Other/Unspecified = 26 %
Single parent household (%)
42.1 %
Family unemployment (%)
25.1 %
Maternal education high school/GED or less (%)
41.6 %
Family income Median = $40,000 Child and family clinical measures CBCL Child internalizing problems (T-score)
M = 66.15 (SD = 9.41; 58.5 % above clinical cutoff score)
CBCL Child externalizing problems (T-score)
M = 73.92 (SD = 11.95; 78.7 % above clinical cutoff score)
PPVT-IV Child receptive language (T-score)
M = 99.61 (SD = 16.13)
CESD Maternal depression
M = 20.53 (SD = 12.40; 52.5 % above clinical cutoff score)
PSI Maternal parenting stress
M = 102.18; SD = 21.29; 73.2 % above clinical cutoff score)
CBCL = Child Behavior Checklist [28] (clinical range C 64); PPVT-IV = Peabody Picture Vocabulary Test [29] (Mean = 100; SD = 15); CESD = Center for Epidemiological Studies Depression Scale [30] (clinical cutoff score [ 16); PSI = Parenting Stress Index [31] (clinical cutoff score [ 85th percentile)
proficient in English, and (c) a parent or guardian completed the DIPA sleep disorders module. Data were collected over a period of approximately 4 years, from 2010 to 2013. The hospital’s Institutional Review Board approved all study measures. Children were referred to the day treatment program by community providers (including mental health providers and agencies, pediatricians, medical hospital emergency departments, and school/daycare programs) and presented with a wide variety of significant clinical concerns, including serious other-and self-directed aggression, persistent out-of-control tantrums, anxiety and mood dysregulation, feeding and eating problems, compliance with directions, and general family dysfunction. For most children, these clinical problems were quite severe, with mean parent-reported behavior problem symptoms well beyond established clinical cut-offs on norm-referenced measures of early childhood behavior problems. Families of participating children also presented with high levels of general distress and dysfunction. A summary of child and family clinical characteristics, along with sample demographics, is presented in Table 1.
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Many participating children also presented with other various health and medical concerns. Specifically, 92 children (50.3 %) were identified as having one or more medical problems, the most common of which were asthma (14.8 %), seizures (2.2 %), eczema (2.7 %), and recurrent otitis media (4.9 %). At the time of program admission, 33 (18 %), of participating children were prescribed one or more psychiatric medications, the most common of which were stimulants, alpha agonists, antidepressants, and Melatonin. Participating children attended the day treatment program for an average of 22 program days (Monday–Friday). Children’s length of stay in the program varied according to their clinical needs, progress, and insurance funding. Children received a wide range of clinical services. Additional information about the treatment program model and services is described in a previous report [32]. Measures Diagnostic Infant and Preschool Assessment (DIPA) The DIPA [25] is a semi-structured interview, administered to parents/caregivers of preschool age children under the age of seven, by trained Master’s level or Ph.D. interviewers. The interview assesses 13 disorders (using self-contained modules), allows for interviewer flexibility, and takes about 2 hours to complete. The DIPA was completed during the first week of the child’s admission to the program. The Research Diagnostic Criteria-Preschool Age (RDC-PA) modifications of DSM-IV criteria [33] were used to diagnose psychiatric disorders. The sleep problems module was scored using the RDC sleep disorder suggested frequency, duration, and severity criteria (Fig. 1). Specifically, SOI was diagnosed when children were reported to take more than 20 min to fall asleep (more than 30 min for children 12–24 months of age) at least five nights per week. NWI was diagnosed when children were reported to have one or more awakenings each night for a combined duration of at least 10 min (more than one awakening/20 min and more than three awakenings/30 min for children 24–36 months and 12–24 months, respectively) at least five nights per week. The DIPA has been shown to have acceptable test–retest reliability and criterion validity for commonly occurring DSM-IV diagnoses, including Oppositional Defiant Disorder, Attention-Deficit/Hyperactivity Disorder, and Separation Anxiety Disorder [25]. However, the original validation study did not present data on the DIPA sleep disorders module. For the purposes of the present study, we calculated preliminary inter-rater reliability for a sample of 20 children, with independent coding for sleep disorder diagnosis based on audiotaped recordings of DIPA interviews. Kappa values were 0.70 (85 % agreement) and 0.77 (95 % agreement) for SOI and NWI, respectively, suggesting acceptable to good reliability.
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Sleep Diary The sleep diary is a structured form that asks the parent to note specific sleep-related events on a daily basis. These include bedtimes, times of sleep onset, middle-of-the-night awakenings from sleep and their durations, and morning rise times. Completion of the sleep diary typically takes \ 2 min each morning for the preceding 24 hours. Program staff collected sleep diaries each morning upon arrival to the program. The first week’s five daily sleep diary reports were averaged into a mean score for the following variables: bedtime (recorded clock time from the diary), asleep time (recorded clock time from the diary), sleep onset latency time (number of minutes from bedtime to asleep time), wake after sleep onset (WASO) duration (total minutes awake after sleep onset), WASO number (the number of nighttime awakenings after sleep onset), sleep efficiency (time in bed asleep divided by the total time in bed) and wake up time (recorded clock time from the diary). Child Behavior Checklist for Ages 1–5 (CBCL) Child behavioral impairment was assessed at admission using the CBCL [28], a widely used and well-validated measure of early childhood behavior symptoms. The CBCL includes 99 problem items plus descriptions of problems, disabilities, concerns and strengths, and yields both narrowband and broadband scales of children’s behavioral adjustment. For this report, the narrowband Sleep Problems and broadband Total Problems scales were analyzed. Data Analysis Frequency distributions and Chi square analyses were used to examine the prevalence and co-occurrence of sleep and other psychiatric disorders evidenced by the young children in this acute clinical sample, as assessed using the DIPA. One-way ANOVAs (with two-tailed tests of significance) were then used to compare sleep diary and CBCL Sleep and Total problem scores for children who did and did not meet criteria for one or more DIPA-defined sleep disorders.
Results Sleep Insomnias and Other Psychiatric Disorders: Descriptive Analyses Children presented with a wide range of DIPA/DSM-IV diagnoses and many children presented with multiple
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diagnoses. Sleep disorders were among the most common disorders diagnosed. Specifically, using DIPA-derived RDC sleep insomnia criteria (Fig. 1), 76 children (41 %) met criteria for one or both sleep insomnias. With respect to specific insomnias, 42 children (23 %) met criteria for SOI and 8 children (4 %) met criteria for NWI. Not surprisingly, SOI and NWI were highly comorbid, with an additional 26 children (14 %) meeting criteria for both (considered a ‘‘mixed’’ insomnia). The number of children who met criteria for other DIPA-diagnosed DSM-IV disorders [28] were as follows: 140 (76.5 %) children met criteria for ODD, 94 (51.4 %) of children met criteria for ADHD, 40 (21.9 %) children met criteria for MDD, and 75 (41.0 %) children met criteria for one or more anxiety disorders (including GAD, SAD, and social phobia).1 We next used Chi square analyses to examine the extent to which DIPA diagnosed sleep disorders co-occurred with other psychiatric disorders. As shown in Table 2, the associations between RDC sleep insomnia (including SOI, NWI, or both) and ODD, ADHD, MDD, and anxiety disorder were all significant, suggesting that sleep disorders commonly occurred in the context of other diagnosed psychiatric disorders.
Table 2 Associations between DIPA sleep and other psychiatric disorders DIPA diagnoses
Sleep disorder absent (n = 107)
Sleep disorder present (n = 76)
V2
p
Oppositional defiant disorder (ODD) Present (n = 140)
74 (52.9 %)
66 (47.1 %)
Absent (n = 43)
33 (76.7 %)
10 (23.3 %)
7.73
.01
Attention-deficit/hyperactivity disorder (ADHD) Present (n = 94)
45 (47.9 %)
49 (52.1 %)
Absent (n = 89)
62 (69.7 %)
17 (30.3 %)
8.94 \.01
Anxiety disorder (GAD, SAD, or social phobia) Present (n = 75)
34 (45.3 %)
41 (54.7 %)
Absent (n = 108)
73 (67.6 %)
35 (32.4 %)
9.03 \.01
Major depressive disorder (MDD) Present (n = 40)
15 (37.5 %)
25 (62.5 %)
Absent (n = 143)
92 (64.3 %)
51 (35.7 %)
12.73 \.01
Sleep–Wake Patterns and Behavioral Problems in Children with Sleep Insomnias We then examined parent-reported sleep–wake patterns, sleep-related behavior concerns, and total behavior problems for children who did and did not meet RDC sleep insomnia criteria. Specifically, we computed ANOVAs to compare sleep diary and CBCL Sleep and Total Problems scores for children without a DIPA-defined sleep insomnia, children who met DIPA criteria for SOI only, and children who met criteria for SOI plus NWI (mixed insomnia group). Given that only eight children met criteria for NWI in the absence of SOI, we did not have adequate statistical power to include an NWI only group and these eight children were excluded from these analyses. Results are presented in Table 3. As shown, statistically significant differences were found among the three sleep groups (i.e., no sleep disorder, SOI only, and SOI ? NWI) for 6 of the 8 sleep diary variables, as well as for the Sleep and Total Problems scales of the CBCL. Post hoc Tukey HSD tests (see Figs. 2a–f) indicated that the SOI groups (both with and without NWI) had significantly longer sleep latency times and less total sleep times as compared with the group who did not have a DIPA diagnosed sleep 1
Percentages do not sum to 100 % because diagnoses were not mutually exclusive and many children met criteria for multiple diagnoses. For example, 17.4 % of children met criteria for two diagnoses and 43.2 % of children met criteria for three or more diagnoses.
insomnia. Children who met DIPA criteria for a mixed insomnia (SOI ? NWI) had more nighttime awakenings (WASO), as compared to children who did not have a sleep disorder or who had SOI only. Duration of these awakenings was also longest for the mixed SOI ? NWI group. All three groups differed significantly from each other with respect to sleep efficiency. Finally, parent-reported sleep concerns on the CBCL Sleep Problems scale were significantly less for children who did not meet DIPA criteria for a sleep insomnia compared with those that did, with the greatest concerns reported for the SOI ? NWI group. With respect to the CBCL Total Problems scale, children with no diagnosed sleep disorder were reported to have fewer problems (M = 68.45, SD = 9.34) than either the SOI only (M = 73.54, SD = 9.34) or the SOI ? NWI group (M = 76.40, SD = 7.19), F (2, 157) = 9.78, p \ .01.
Discussion This study focused on the nature and prevalence of sleep disorders in an acute clinical sample of preschool age children. Forty-one percent of the sample met DIPA criteria for a sleep insomnia, a prevalence that exceeds the 20–30 % of typically developing toddlers and preschoolers reported in the extant literature [34]. Problems with falling asleep, either as the only problem (23 %), or falling asleep
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Child Psychiatry Hum Dev Table 3 Sleep diary patterns and CBCL sleep problems in children with and without sleep disorders No sleep disorder N = 107
Sleep Onset Insomnia only N = 42
Sleep Onset ? Night Waking Insomnia N = 34
Bedtime Mean (SD) Range Asleep time
20:22 (0:44)
20:24 (0:51)
20:02 (1:02)
18:00–22:20
19:00–22:40
16:48–23:05
Mean (SD)
20:55 (0:55)
21:20 (1:09)
21:13 (1:20)
Range
18:27–23:29
19:33–24:33
18:30–24:54
F (2, 172) = 1.98, p = .14
F (2, 172) = 2.70, p = .07
Sleep onset latency Mean (SD)
0:33 (0:32)
0:57 (0:49)
1:13 (0:40)
Range
0:00–2:33
0:00–2:54
0:00–2:56
F (2, 172) = 13.76, p \ .001
Number WASOs Mean (SD)
0.5 (0.68)
0.8 (0.72)
1.3 (0.81)
Range
0.00–3.00
0.00–2.60
0.00–3.50
Mean (SD)
0:03 (0:03)
0:13 (0:13)
0:31 (0:31)
Range
0:00–0:35
0:00–1:54
0:00–3:20
F (2, 171) = 13.63, p \ .001
Duration WASOs F (2, 171) = 19.74, p \ .001
Wake-up time Mean (SD) Range Total sleep time
06:50 (0:35)
06:56 (0:41)
06:38 (0:40)
4:37–8:30
5:24–8:16
4:54–7:52
Mean (SD)
9:49 (0:51)
9:22 (1:03)
8:54 (1:28)
Range
7:28–11:51
6:08–11:05
5:12–11:14
F (2, 171) = 1.87, p = .16
F (2, 170) = 9.76, p \ .001
Sleep efficiency Mean (SD)
93.7 (5.61)
89.0 (9.23)
83.1 (10.20)
Range
71.3–100.4
64.3–100.2
56.1–100.0
F (2, 170) = 23.1, p \ .001
CBCL sleep problems Mean (SD)
59.0 (9.46)
69.8 (12.30)
79.9 (12.34)
Range
50–100
50–100
59–100
F (2, 157) = 44.0, p \ .001
WASO Waking after sleep onset, CBCL child behavior checklist
problems mixed with subsequent nighttime awakenings (14 %) were the predominant behavioral insomnias of childhood. It is interesting to speculate that the paucity of night waking only problems (4 %) reported for these children might reflect a general disorganization in these households where night waking might not be accompanied by signaling or signaling might not be heard by exhausted parents. As such, our estimated rates of NWI may be conservative, given our reliance on parental report for the assessment of nighttime arousals. Actigraphy studies could provide additional information about unreported night waking. We also examined diagnosed sleep disorders as related to parent-reported sleep-wake patterns (as assessed using daily sleep diaries over five nights) and general sleep concerns (as assessed using the Sleep Problems scale of the CBCL). Indeed, daily sleep diaries were significantly related to DIPA diagnoses of SOI and
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mixed sleep onset and Night Waking Insomnia (SOI ? NWI). Children who did not meet criteria for a DIPA sleep insomnia slept significantly more efficiently with shorter sleep onset latency times, shorter middle of the night awakenings, and longer total sleep time. The SOI and SOI ? NWI groups were further distinguished in that the SOI ? NWI group demonstrated the least efficient sleep and the lengthiest night awakenings, as well as the highest scores on the CBCL sleep concerns scale (see Fig. 2a–f). Such sleep deprivation is of significant clinical concern, given the associations between sleep disruption and behavioral disturbance, cognitive impairment, and deficits in attentiveness. Interestingly, evening bedtimes and morning wake-up times were not different for the sleep disordered and non-sleep disordered groups, suggesting that the different sleep patterns observed in these groups were not merely due to differences in family schedules and daily routines. It is also
Child Psychiatry Hum Dev Fig. 2 Sleep diary patterns in children, with no sleep disorder, Sleep Onset Insomnia (SOI), and Sleep Disorder ? Night Waking Insomnia (SOI ? NWI). a Differences in mean sleep onset latency (minutes) between groups. Different letters denote that groups are significantly different, p \ .05. b Differences in mean number of wakening after sleep onset (WASO) between groups. Note. Different letters denote that groups are significantly different, p \ .05. c Differences in mean duration (minutes) of wakening after sleep onset (WASO) between groups. Different letters denote that groups are significantly different, p \ .05. d Differences in mean total sleep time (minutes) between groups. Different letters denote that groups are significantly different, p \ .05. e Differences in mean sleep efficiency between groups. Different letters denote that groups are significantly different, p \ .05. f Differences in mean CBCL sleep problems between groups. Different letters denote that groups are significantly different, p \ .05
(a)
(d)
80
590 580 570 560 550 540 530 520 510 500
b
70
b
60 50 40
a
30 20 10 0 No Sleep Disorder
SOI
(e)
b
1.2 1
a
0.8 0.6
a
0.4 0.2 0
(c)
No Sleep Disorder
SOI
b
94 92 90 88 86 84 82 80 78 76
c
b c
SOI
70
25
60
SOI + NWI
c
80
30
SOI + NWI
a
No Sleep Disorder
SOI + NWI
SOI
(f)
35
b a
50
20
40
b
15
30
10 5
b
No Sleep Disorder
SOI + NWI
(b) 1.4
a
20
a
10 0
0 No Sleep Disorder
SOI
possible that similarities in morning wake times were related to the pre-determined rise times required for participation in the day treatment program. Taken together, these study results contribute to the literature on early childhood sleep problems in several ways. Most importantly, we are aware of no previous study examining diagnostically defined sleep disorders in a clinical sample of preschool-aged children. The young children who participated in this study demonstrated a wide range of psychiatric problems, among which sleep disorders were common. Moreover, sleep problems typically cooccurred with other psychiatric diagnoses and were also associated with increased parent-reported behavioral concerns, both sleep and non-sleep related. Such findings suggest that, for some young children, sleep problems may
SOI + NWI
No Sleep Disorder
SOI
SOI + NWI
be part of a diagnostically complex clinical picture characterized by a range of difficulties with emotional, behavioral and physiological self-regulation. Moreover, it is likely that these early childhood sleep and other behavioral problems are mutually intensifying, with disrupted sleep associated with increased emotional and behavioral dysregulation and with psychiatric symptoms (such as anxiety and agitation) associated with difficulties initiating and maintaining sleep. It is also likely that there are other, shared risk factors (e.g., family disorganization or stress) that contribute to both disrupted sleep and behavior problems in these clinically referred young children. Study findings also point to the need to assess and treat early childhood sleep problems, even when such problems are not the primary presenting clinical concern. In addition
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to the likely possibility that poor sleep serves to exacerbate co-occurring behavioral problems in young children, it may also be the case that sleep problems negatively impact the effectiveness of treatments to address primary behavioral concerns. For example, sleep-deprived children (and parents) may be too exhausted to benefit from interventions aimed to promote behavioral and emotional self-regulation. Further, in our own clinical experience, we have found that improvements in child sleep are frequently associated with improved daytime behavioral functioning, as well as providing families with renewed energy and positive momentum to tackle other behavioral concerns and clinical problems. In addition, although the nomenclature for diagnosing sleep disorders in young children remains controversial, findings of the present study suggest that SOI and NWI (and mixed SOI ? NWI) are useful descriptions for behavioral sleep problems as evidenced by very young children. Difficulties initiating and sustaining sleep may be distinct, but related facets of early sleep dysregulation, with some children demonstrating primary difficulties settling at bedtime (SOI) and other children demonstrating more recurring episodes of arousal and awakening at both bedtime and throughout the night (SOI ? NWI). Future research will be needed to determine whether difficulties with night waking (either alone or in combination with sleep onset problems) represent a qualitatively different aspect of sleep disturbance, or rather whether the mixed SOI ? NWI group may simply represent children with the most pervasive and impairing sleep problems.2 Future research will also be needed to examine the links between early childhood insomnias and pediatric sleep concerns not assessed in the DIPA, such as obstructive sleep apnea and night terror and sleepwalking parasomnias. Finally, this study is the first to report on the criterion validity of DIPA sleep disorders module, with findings demonstrating that DIPA-derived sleep disorder diagnoses related—in expectable ways—to data obtained using daily sleep diaries and the sleep problems scale of the CBCL. Moreover, the DIPA sleep disorders module may offer several important clinical advantages over these and other available sleep assessment tools, many of which are costly, time-consuming, and challenging to incorporate into routine practice. Studies comparing clinical data collected using the DIPA with that collected using both paper instruments and device-based measurements (particularly with respect to night waking episodes) will be an important next step in determining when and how the DIPA sleep module might be put to best clinical use, either alone or in
combination with other sleep assessment tools. Future research will also be needed to more fully evaluate the psychometric properties of the DIPA sleep disorders module, including more rigorous assessment of both interrater and test–retest reliability. While findings of the present study offer an important insight into the nature and diagnostic assessment of sleep problems in psychiatrically impaired preschoolers, several study limitations are of note. Although this is a carefully diagnosed group of seriously disordered preschool age children attending a partial hospital treatment program, the absence of a typically developing, age-matched control group, precludes certainty that our findings are specific to this population. However, our results are consistent with studies conducted with older children and adolescents that suggest that developmentally and behaviorally disordered youth are at increased risk for sleep problems. In addition, our study design did not include tracking of children’s naps. As some of the younger children were able to nap during the day in the program, total daily sleep may have been underestimated for these children. As well, given that children were assessed shortly after program admission, we did not focus on the impact of specific clinical interventions on children’s sleep (e.g., recommended changes in sleep hygiene). Relatedly, as psychopharmacology was not controlled, we cannot know the extent to which drug effects (both sedating and arousing) might have influenced children’s sleep. Finally, the early childhood day program from which our sample was drawn represents a highly specialized and possibly unique treatment setting and the extent to which findings might be generalized to young children treated in other, more typical or less intensive mental health settings is not known. In addition, future longitudinal research will be important in examining questions of temporal causality, including changes in sleep and behavior during treatment. For example, do sleep problems improve before behavior change, or conversely, does behavior change lead to better sleep? How can interventions for sleep disorders be best incorporated into the treatment regimens of seriously behaviorally disordered children? With notable exceptions [35], few studies have examined the impact of sleepfocused interventions for young children with acute psychiatric disorders, and we are aware of no studies that have done so with children and families experiencing such heightened levels of stress and psychopathology as in the present clinical sample.
Summary 2
We appreciated the comments of an anonymous reviewer who suggested ideas about a continuum of severity and shared arousal processes.
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Sleep problems are a significant clinical concern for many young children and their families. Although most research
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in this area has focused on samples drawn from the community and general pediatric practices, children with emotional and behavioral problems may be at particular risk. This study focused on the nature and prevalence of diagnostically defined sleep disorders, including SOI and NWI in a sample of 183 preschoolers (M age = 50.4 months) participating in a psychiatric day treatment program for young children with emotional and behavioral disorders. The Diagnostic Infant and Preschool Assessment (DIPA) was used to assess for SOI and NWI, using RDC. Findings suggested that sleep disorders were quite common in this acute clinical sample, with 41 % of participating children meeting criteria for a DIPA-defined sleep disorder and with sleep onset difficulties (either with or without night waking) being the most common sleep problem described. Parent-reported sleep concerns and diary sleep patterns of children who met criteria for a DIPA sleep disorder demonstrated significant differences from the patterns of children who did not meet DIPA criteria, with sleep-disordered children demonstrating longer latency to sleep onset, longer and more frequent night awakenings, less total sleep time, and lower sleep efficiency. Findings underscore the importance of assessing and treating disordered sleep in young children presenting with co-occurring psychiatric diagnoses and diverse behavioral impairments. Acknowledgments We are grateful to the children and parents who participated in this study. We also thank Mia DeMarco for her helpful assistance with this research project.
References 1. Mindell JA, Emslie G, Blumer J, Genel M, Glaze D, Ivanenko A et al (2006) Pharmacologic management of insomnia in children and adolescents: consensus statement. Pediatrics 117:e1223– e1232 2. Anders TE, Dahl R (2007) Classifying sleep disorders in infants and toddlers. In: Nafrrow WE, First MB, Sirovatka PJ, Regier DA (eds) Age and gender considerations in psychiatric diagnosis: a research agenda for DSM-V. American Psychiatric Publishing, Arlington, pp 215–226 3. Ferber R, Kryger M (1995) Principles and practice of sleep medicine in the child. W.B. Saunders, Philadelphia 4. Lam P, Hiscock H, Wake M (2003) Outcomes of infant sleep problems: a longitudinal study of sleep, behavior, and maternal well-being. Pediatrics 111:E203–E207 5. Lozoff B, Askew GL, Wolf AW (1996) Cosleeping and early childhood sleep problems: effects of ethnicity and socioeconomic status. J Dev Behav Pediatr 17:9–15 6. Ottaviano S, Giannotti F, Cortesi F, Bruni O, Ottaviano C (1996) Sleep characteristics in healthy children from birth to 6 years in the urban area of Rome. Sleep 19:1–3 7. Sadeh A, Gruber R, Raviv A (2002) Sleep, neurobehavioral functioning, and behavior problems in school-age children. Child Dev 73:405–417
8. Smedje H, Broman JE, Hetta J (2001) Associations between disturbed sleep and behavioural difficulties in 635 children aged six to eight years: a study based on parents’ perceptions. Eur Child Adolesc Psychiatry 10:1–9 9. Kateria S, Swanson M, Trevarthin G (1987) Persistence of sleep disturbances in preschool children. J Pediatr 110:642–646 10. Goodlin-Jones BL, Tang K, Liu J, Anders TF (2008) Sleep patterns in preschool-age children with autism, developmental delay, and typical development. J Am Acad Child Adolesc Psychiatry 47:930–938 11. Wiggs L, Stores G (1996) Severe sleep disturbance and daytime challenging behaviour in children with severe learning disabilities. J Intellect Disabil Res 40:518–528 12. Willoughby MT, Angold A, Egger HL (2008) Parent-reported attention-deficit/hyperactivity disorder symptomatology and sleep problems in a preschool-age pediatric clinic sample. J Am Acad Child Adolesc Psychiatry 47:1086–1094 13. Bates JE, Viken RJ, Alexander DB, Beyers J, Stockton L (2002) Sleep and adjustment in preschool children: sleep diary reports by mothers relate to behavior reports by teachers. Child Dev 73:62–74 14. Lavigne JV, Arend R, Rosenbaum D, Smith A, Weissbluth M, Binns HJ et al (1999) Sleep and behavior problems among preschoolers. J Dev Behav Pediatr 20:164–169 15. Marcotte AC, Thacher PV, Butters M, Bortz J, Acebo C, Carskadon MA (1998) Parental report of sleep problems in children with attentional and learning disorders. J Dev Behav Pediatr 19:178–186 16. Dahl RE (1996) The impact of inadequate sleep on children’s daytime cognitive function. Semin Pediatr Neurol 3:44–50 17. Alfano CA, Gamble AL (2009) The Role of sleep in childhood psychiatric disorders. Child Youth Care Forum 38:327–340 18. Lavigne JV, Arend R, Rosenbaum D, Smith A, Weissbluth M, Binns HJ, Christofell KK (1999) Sleep and behavior problems among preschoolers. J Dev Behav Pediatr 20:164–169 19. Steinsbekk S, Berg-Nielsen TS, Wichstrom L (2013) Sleep disorders in preschoolers: prevalence and comorbidity with psychiatric symptoms. J Dev Behav Pediatr 34:633–641 20. Ivanenko A, Johnson K (2008) Sleep disturbances in children with psychiatric disorders. Semin Pediatr Neurol 15:70–78 21. Gregory AM, Sadeh A (2012) Sleep, emotional and behavioral difficulties in children and adolescents. Sleep Med Rev 16:129–136 22. Lavigne JV, LeBailly SA, Hopkins J, Gouze KR, Binns HJ (2009) The prevalence of ADHD, ODD, depression, and anxiety in a community sample of 4-year-olds. J Clin Child Adolesc Psychol 38:315–328 23. Luby JL (2012) About 7% of 4-year-olds in Norway meet criteria for a psychiatric diagnosis. Evid Based Ment Health 15:108 24. ICSD-DCM2 (2005) The international classification of sleep disorders, diagnostic and coding manual. American Academy of Sleep Medicine, Minneapolis 25. Scheeringa MS, Haslett N (2010) The reliability and criterion validity of the Diagnostic Infant and Preschool Assessment: a new diagnostic instrument for young children. Child Psychiatry Hum Dev 41:299–312 26. Egger HL, Angold A (2006) Common emotional and behavioral disorders in preschool children: presenation, nosology, and epidemiology. J Child Psychol Psychiatry 47:313–337 27. Gregory AM, Cousins JC, Forbes EE, Trubnik L, Ryan ND, Axelson DA et al (2011) Sleep items in the child behavior checklist: a comparison with sleep diaries, actigraphy, and polysomnography. J Am Acad Child Adolesc Psychiatry 50:499–507 28. Achenbach TM, Rescorla LA (2000) Manual for the ASEBA school-age forms & profiles. University of Vermont Research Center for Children, Youth & Families, Burlington
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Child Psychiatry Hum Dev 29. Dunn LM, Dunn DM (2007) PPVT-4: peabody picture vocabulary test. NCS Pearson Inc, Bloomington 30. Radloff LS (1977) The CES-D scale: a self-report depression scale for research in the general population. Appl Pyschol Meas 1:385–401 31. Abidin RR (1995) Parenting Stress Index, 3rd edn. Psychological Assessment Resources, Odessa 32. Martin SE, McConville DM, Williamson LR, Feldman G, Boekamp JR (2013) Partial hospital treatment for preschoolers with severe behavior problems: child age and maternal functioning as predictors of outcome. Child Adol Ment Health 18:24–32
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33. Task Force on Research Diagnostic Criteria: Infancy and Preschool (2003) Research diagnostic criteria for infants and preschool children: the process and empirical support. J Am Acad Child Adolesc Psychiatry 42:1504–1512 34. Polimeni MA, Richdale AL, Francis AJ (2005) A survey of sleep problems in autism, Asperger’s disorder and typically developing children. J Intellect Disabil Res 49:260–268 35. Minde K, Faucon A, Falkner S (1994) Sleep problems in toddlers: effects of treatment on their daytime behavior. J Am Acad Child Adolesc Psychiatry 33:1114–1121
ORIGINAL ARTICLE
Sleep Onset and Night Waking Insomnias in Preschoolers with Psychiatric Disorders John R. Boekamp • Lauren R. Williamson Sarah E. Martin • Heather L. Hunter • Thomas F. Anders
•
Ó Springer Science+Business Media New York 2014
Abstract This study examined the nature and prevalence of diagnostically defined sleep disorders, including Sleep Onset Insomnia (SOI) and Night Waking Insomnia (NWI), in a sample of 183 young children admitted to an early childhood psychiatric day treatment program. A semistructured diagnostic interview, the Diagnostic Infant and Preschool Assessment, was used to assess for sleep and other psychiatric disorders. Daily sleep diaries and the Child Behavior Checklist were also examined. 41 % of children met criteria for a sleep disorder; 23 % met diagnostic criteria for SOI and 4 % met criteria for NWI, with an additional 14 % meeting criteria for both (SOI ? NWI). Sleep-disordered children demonstrated longer latency to sleep onset, longer and more frequent night awakenings, less total sleep, and lower sleep efficiency than non-sleep disordered participants. Diagnosable sleep disorders, particularly SOI, were quite common in this acute clinical sample, exceeding previous estimates obtained in community and pediatric practice samples.
J. R. Boekamp H. L. Hunter T. F. Anders Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA J. R. Boekamp (&) Bradley Hospital, 1011 Veterans Memorial Parkway, East Providence, RI 02915, USA e-mail: [email protected] L. R. Williamson S. E. Martin H. L. Hunter Bradley Hospital, East Providence, RI, USA S. E. Martin Department of Psychology, Simmons College, Boston, MA, USA
Keywords Preschoolers Sleep disorders Sleep diaries Psychopathology Diagnostic interview
Introduction The most common sleep difficulties reported for toddlers and preschoolers in Western cultures are problems of going to bed, falling asleep and frequent night awakenings; collectively these problems are referred to as behavioral insomnias of childhood [1–3]. Prevalence estimates for behavioral insomnias are up to 30 % in typically developing preschool age children and are even higher in those with neurodevelopmental impairments, such as autism, learning disorders and intellectual disability [4–11]. In addition, sleep problems in young children frequently cooccur with other behavioral problems, with evidence that inadequate sleep is associated with daytime sleepiness [12], less optimal preschool adjustment [13], and problems of irritability, hyperactivity and attention [4, 14–16]. Moreover, it is likely that the links between early childhood psychiatric symptoms and sleep disturbance are bi-directional and mutually exacerbating [17]. That is, early sleep problems may be both a cause and consequence of cooccurring difficulties with behavioral and emotional selfregulation, with sleep disruption affecting psychiatric symptoms and psychiatric symptoms affecting sleep–wake organization. To date, most research examining the links between early childhood sleep and behavioral problems has focused on typically developing young children, based on samples drawn from the community and general pediatric practices [13, 18, 19]. In contrast, there has been relatively less attention devoted to understanding the nature and prevalence of sleep problems in young children presenting with
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Child Psychiatry Hum Dev Fig. 1 RDC criteria for Sleep Onset Insomnia and Night Waking Insomnia in toddlers and preschoolers. Sleep onset and Night Waking Insomnias are not diagnosed before 1 year of age. The criteria pertain to solitary sleeping toddlers and preschoolers. a5–7 episodes/ week for at least 1 month are most likely continuous and require intervention. bReunions reflect resistances in going to bed (e.g., repeated bids, protests, struggles). c Awakenings usually require parental intervention and occur after the child has been asleep for [10 min
SLEEP ONSET INSOMNIA A. Symptoms present for at least four weeks and involve 5 – 7 episodes per weeka B. Significant difficulty falling asleep Suggested cut-offs for duration and severity (any two of three criteria listed): 12-24 months of age:
(1) > 30 minutes to fall asleep (2) parent remains in room for sleep onset (3) 3 or more reunionsb
> 24 months of age:
(1) > 20 minutes to fall asleep (2) parent remains in room for sleep onset (3) 2 or more reunionsb
NIGHT WAKING INSOMNIA A. Symptoms present for at least four weeks and involve 5 – 7 episodes per week a B. Significant difficulty staying asleep Suggested cut-offs for duration and severity: c
12-24 months of age:
3 or more awakenings > 30 minutes
24-36 months of age:
1 or more awakenings > 20 minutes
>36 months of age:
1 or more awakenings > 10 minutes
c
clinically significant diagnosed psychiatric disorders, despite compelling evidence for elevated rates of sleep problems in older children and adolescents with specific DSM-IV psychiatric disorders. For example, two extensive recent reviews suggest that, in school-aged children and adolescents, psychiatric disorders and sleep disorders are highly co-morbid [20, 21]. The lack of research on sleep in preschool age children with psychiatric disorders represents a significant gap in the early childhood mental health literature, particularly given increasing awareness of the prevalence and seriousness of mental health problems in early childhood [22, 23]. In addition, it is important that research on sleep disruption in young children with emotional and behavioral problems include attention to diagnostically defined sleep disorders. This perspective is well articulated by Steinsbekk, Berg-Nielsen, and Wichstrom (2013), who noted that symptoms of sleep problems may not translate directly into specific sleep disorders. These researchers examined the prevalence of diagnosed sleep disorders (including insomnia, hypersomnia, nightmare disorder, and sleepwalking disorder) in a large, screen-stratified sample of Norwegian preschoolers and found that such disorders were relatively common and were frequently associated with other DSM-IV diagnoses, particularly anxiety disorders [19]. Such findings further underscore the importance
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c
of examining sleep problems in preschoolers presenting with clinically significant emotional and behavioral impairments and to do so using diagnostically defined sleep disorder criteria. The International Classification of Sleep Disorders Diagnostic and Coding Manual, 2nd Edition (ICSDDCM2) [24] sub classifies the behavioral insomnias into a number of sub-categories including Limit-Setting Sleep Disorder and Sleep-Onset Association Disorder. The former is characterized by ‘‘the inadequate enforcement of bedtimes by a caretaker with resultant stalling or refusal to go to bed at an appropriate time,’’ and is used to define falling asleep problems. The latter occur ‘‘when sleep onset is impaired by the absence of a certain object or set of circumstances,’’ and is used for middle-of-the-night awakening problems. Both of the disorders are further defined by duration (acute, sub-acute, chronic) and severity criteria (mild, moderate, severe). Anders and Dahl [2] proposed research diagnostic criteria (RDC) for these two diagnostic subtypes: Sleep Onset Insomnia (SOI) and Night Waking Insomnia (NWI), suggesting more quantitative and developmentally sensitive duration and severity criteria and de-emphasizing the etiologic roles of learning and conditioning as criterion for diagnosis (Fig. 1). The RDC sleep disorder criteria proposed by Anders and Dahl have been incorporated into the recently developed
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Diagnostic Infant and Preschool Assessment [25], a semistructured diagnostic interview for the clinical assessment of very young children. The availability of this and similar interview-based tools that include modules for the diagnosis of early childhood sleep disorders [26] is of importance to practicing clinicians, given that other sleep assessment techniques may be time-consuming (e.g., lengthy questionnaires, sleep diaries) or require specialized technology or training (e.g., actigraphy, polysomnography), and as such, are unlikely to be feasible in a busy clinical practice, particularly when sleep is not the presenting complaint. On the other hand, brief rating scales and scales that assess only general aspects of sleep disruption have been criticized for lack of diagnostic specificity [27]. Yet despite the availability and potential clinical advantages of diagnostic interviews that include modules for the assessment of early sleep disorders, only a few studies have empirically examined the use of these modules [12, 19] and we are aware of none that have done so in a preschool psychiatric sample. The primary goal of this study was to examine the prevalence of SOI and NWI, based on RDC and as assessed using the Diagnostic Infant and Preschool Assessment (DIPA), in a sample of very young children attending an intensive psychiatric day treatment program. In addition, we examined the associations between sleep insomnias and other DIPA-diagnosed psychiatric disorders, including Oppositional Defiant Disorder (ODD), Attention-Deficit/ Hyperactivity Disorder (ADHD), Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), Separation Anxiety Disorder (SAD), and Social Phobia. Given that the original validation study for the DIPA [25] did not present data on the DIPA sleep disorders module, an additional aim of the present study was to examine the concurrent criterion validity of DIPA-derived SOI and NWI diagnoses, as compared to daily sleep diaries and the sleep problems scale of the Child Behavior Checklist [28].
Methods Participants Participants were 183 children (ages 19–71 months, M = 50.4 months, SD = 12.5 months) who presented to a hospital-based day treatment program for young children with severe emotional and behavioral problems. A parent or guardian provided informed consent for child and family participation in the study. Participating parents were, on average, 31 years of age and most (89 %) were the biological mother of the participating child. Additional criteria for inclusion in this study included: (a) the participating child was under 6 years of age, (b) the family was
Table 1 Demographic and clinical characteristics of the sample Demographic characteristics Gender of child
73.2 % male
Age of child
M = 50.4 months (SD = 12.5)
Child ethnicity (%)
White/Non-hispanic = 54 % Black/African-American = 18 % Hispanic/Latino = 15 % Other/Unspecified = 26 %
Single parent household (%)
42.1 %
Family unemployment (%)
25.1 %
Maternal education high school/GED or less (%)
41.6 %
Family income Median = $40,000 Child and family clinical measures CBCL Child internalizing problems (T-score)
M = 66.15 (SD = 9.41; 58.5 % above clinical cutoff score)
CBCL Child externalizing problems (T-score)
M = 73.92 (SD = 11.95; 78.7 % above clinical cutoff score)
PPVT-IV Child receptive language (T-score)
M = 99.61 (SD = 16.13)
CESD Maternal depression
M = 20.53 (SD = 12.40; 52.5 % above clinical cutoff score)
PSI Maternal parenting stress
M = 102.18; SD = 21.29; 73.2 % above clinical cutoff score)
CBCL = Child Behavior Checklist [28] (clinical range C 64); PPVT-IV = Peabody Picture Vocabulary Test [29] (Mean = 100; SD = 15); CESD = Center for Epidemiological Studies Depression Scale [30] (clinical cutoff score [ 16); PSI = Parenting Stress Index [31] (clinical cutoff score [ 85th percentile)
proficient in English, and (c) a parent or guardian completed the DIPA sleep disorders module. Data were collected over a period of approximately 4 years, from 2010 to 2013. The hospital’s Institutional Review Board approved all study measures. Children were referred to the day treatment program by community providers (including mental health providers and agencies, pediatricians, medical hospital emergency departments, and school/daycare programs) and presented with a wide variety of significant clinical concerns, including serious other-and self-directed aggression, persistent out-of-control tantrums, anxiety and mood dysregulation, feeding and eating problems, compliance with directions, and general family dysfunction. For most children, these clinical problems were quite severe, with mean parent-reported behavior problem symptoms well beyond established clinical cut-offs on norm-referenced measures of early childhood behavior problems. Families of participating children also presented with high levels of general distress and dysfunction. A summary of child and family clinical characteristics, along with sample demographics, is presented in Table 1.
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Many participating children also presented with other various health and medical concerns. Specifically, 92 children (50.3 %) were identified as having one or more medical problems, the most common of which were asthma (14.8 %), seizures (2.2 %), eczema (2.7 %), and recurrent otitis media (4.9 %). At the time of program admission, 33 (18 %), of participating children were prescribed one or more psychiatric medications, the most common of which were stimulants, alpha agonists, antidepressants, and Melatonin. Participating children attended the day treatment program for an average of 22 program days (Monday–Friday). Children’s length of stay in the program varied according to their clinical needs, progress, and insurance funding. Children received a wide range of clinical services. Additional information about the treatment program model and services is described in a previous report [32]. Measures Diagnostic Infant and Preschool Assessment (DIPA) The DIPA [25] is a semi-structured interview, administered to parents/caregivers of preschool age children under the age of seven, by trained Master’s level or Ph.D. interviewers. The interview assesses 13 disorders (using self-contained modules), allows for interviewer flexibility, and takes about 2 hours to complete. The DIPA was completed during the first week of the child’s admission to the program. The Research Diagnostic Criteria-Preschool Age (RDC-PA) modifications of DSM-IV criteria [33] were used to diagnose psychiatric disorders. The sleep problems module was scored using the RDC sleep disorder suggested frequency, duration, and severity criteria (Fig. 1). Specifically, SOI was diagnosed when children were reported to take more than 20 min to fall asleep (more than 30 min for children 12–24 months of age) at least five nights per week. NWI was diagnosed when children were reported to have one or more awakenings each night for a combined duration of at least 10 min (more than one awakening/20 min and more than three awakenings/30 min for children 24–36 months and 12–24 months, respectively) at least five nights per week. The DIPA has been shown to have acceptable test–retest reliability and criterion validity for commonly occurring DSM-IV diagnoses, including Oppositional Defiant Disorder, Attention-Deficit/Hyperactivity Disorder, and Separation Anxiety Disorder [25]. However, the original validation study did not present data on the DIPA sleep disorders module. For the purposes of the present study, we calculated preliminary inter-rater reliability for a sample of 20 children, with independent coding for sleep disorder diagnosis based on audiotaped recordings of DIPA interviews. Kappa values were 0.70 (85 % agreement) and 0.77 (95 % agreement) for SOI and NWI, respectively, suggesting acceptable to good reliability.
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Sleep Diary The sleep diary is a structured form that asks the parent to note specific sleep-related events on a daily basis. These include bedtimes, times of sleep onset, middle-of-the-night awakenings from sleep and their durations, and morning rise times. Completion of the sleep diary typically takes \ 2 min each morning for the preceding 24 hours. Program staff collected sleep diaries each morning upon arrival to the program. The first week’s five daily sleep diary reports were averaged into a mean score for the following variables: bedtime (recorded clock time from the diary), asleep time (recorded clock time from the diary), sleep onset latency time (number of minutes from bedtime to asleep time), wake after sleep onset (WASO) duration (total minutes awake after sleep onset), WASO number (the number of nighttime awakenings after sleep onset), sleep efficiency (time in bed asleep divided by the total time in bed) and wake up time (recorded clock time from the diary). Child Behavior Checklist for Ages 1–5 (CBCL) Child behavioral impairment was assessed at admission using the CBCL [28], a widely used and well-validated measure of early childhood behavior symptoms. The CBCL includes 99 problem items plus descriptions of problems, disabilities, concerns and strengths, and yields both narrowband and broadband scales of children’s behavioral adjustment. For this report, the narrowband Sleep Problems and broadband Total Problems scales were analyzed. Data Analysis Frequency distributions and Chi square analyses were used to examine the prevalence and co-occurrence of sleep and other psychiatric disorders evidenced by the young children in this acute clinical sample, as assessed using the DIPA. One-way ANOVAs (with two-tailed tests of significance) were then used to compare sleep diary and CBCL Sleep and Total problem scores for children who did and did not meet criteria for one or more DIPA-defined sleep disorders.
Results Sleep Insomnias and Other Psychiatric Disorders: Descriptive Analyses Children presented with a wide range of DIPA/DSM-IV diagnoses and many children presented with multiple
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diagnoses. Sleep disorders were among the most common disorders diagnosed. Specifically, using DIPA-derived RDC sleep insomnia criteria (Fig. 1), 76 children (41 %) met criteria for one or both sleep insomnias. With respect to specific insomnias, 42 children (23 %) met criteria for SOI and 8 children (4 %) met criteria for NWI. Not surprisingly, SOI and NWI were highly comorbid, with an additional 26 children (14 %) meeting criteria for both (considered a ‘‘mixed’’ insomnia). The number of children who met criteria for other DIPA-diagnosed DSM-IV disorders [28] were as follows: 140 (76.5 %) children met criteria for ODD, 94 (51.4 %) of children met criteria for ADHD, 40 (21.9 %) children met criteria for MDD, and 75 (41.0 %) children met criteria for one or more anxiety disorders (including GAD, SAD, and social phobia).1 We next used Chi square analyses to examine the extent to which DIPA diagnosed sleep disorders co-occurred with other psychiatric disorders. As shown in Table 2, the associations between RDC sleep insomnia (including SOI, NWI, or both) and ODD, ADHD, MDD, and anxiety disorder were all significant, suggesting that sleep disorders commonly occurred in the context of other diagnosed psychiatric disorders.
Table 2 Associations between DIPA sleep and other psychiatric disorders DIPA diagnoses
Sleep disorder absent (n = 107)
Sleep disorder present (n = 76)
V2
p
Oppositional defiant disorder (ODD) Present (n = 140)
74 (52.9 %)
66 (47.1 %)
Absent (n = 43)
33 (76.7 %)
10 (23.3 %)
7.73
.01
Attention-deficit/hyperactivity disorder (ADHD) Present (n = 94)
45 (47.9 %)
49 (52.1 %)
Absent (n = 89)
62 (69.7 %)
17 (30.3 %)
8.94 \.01
Anxiety disorder (GAD, SAD, or social phobia) Present (n = 75)
34 (45.3 %)
41 (54.7 %)
Absent (n = 108)
73 (67.6 %)
35 (32.4 %)
9.03 \.01
Major depressive disorder (MDD) Present (n = 40)
15 (37.5 %)
25 (62.5 %)
Absent (n = 143)
92 (64.3 %)
51 (35.7 %)
12.73 \.01
Sleep–Wake Patterns and Behavioral Problems in Children with Sleep Insomnias We then examined parent-reported sleep–wake patterns, sleep-related behavior concerns, and total behavior problems for children who did and did not meet RDC sleep insomnia criteria. Specifically, we computed ANOVAs to compare sleep diary and CBCL Sleep and Total Problems scores for children without a DIPA-defined sleep insomnia, children who met DIPA criteria for SOI only, and children who met criteria for SOI plus NWI (mixed insomnia group). Given that only eight children met criteria for NWI in the absence of SOI, we did not have adequate statistical power to include an NWI only group and these eight children were excluded from these analyses. Results are presented in Table 3. As shown, statistically significant differences were found among the three sleep groups (i.e., no sleep disorder, SOI only, and SOI ? NWI) for 6 of the 8 sleep diary variables, as well as for the Sleep and Total Problems scales of the CBCL. Post hoc Tukey HSD tests (see Figs. 2a–f) indicated that the SOI groups (both with and without NWI) had significantly longer sleep latency times and less total sleep times as compared with the group who did not have a DIPA diagnosed sleep 1
Percentages do not sum to 100 % because diagnoses were not mutually exclusive and many children met criteria for multiple diagnoses. For example, 17.4 % of children met criteria for two diagnoses and 43.2 % of children met criteria for three or more diagnoses.
insomnia. Children who met DIPA criteria for a mixed insomnia (SOI ? NWI) had more nighttime awakenings (WASO), as compared to children who did not have a sleep disorder or who had SOI only. Duration of these awakenings was also longest for the mixed SOI ? NWI group. All three groups differed significantly from each other with respect to sleep efficiency. Finally, parent-reported sleep concerns on the CBCL Sleep Problems scale were significantly less for children who did not meet DIPA criteria for a sleep insomnia compared with those that did, with the greatest concerns reported for the SOI ? NWI group. With respect to the CBCL Total Problems scale, children with no diagnosed sleep disorder were reported to have fewer problems (M = 68.45, SD = 9.34) than either the SOI only (M = 73.54, SD = 9.34) or the SOI ? NWI group (M = 76.40, SD = 7.19), F (2, 157) = 9.78, p \ .01.
Discussion This study focused on the nature and prevalence of sleep disorders in an acute clinical sample of preschool age children. Forty-one percent of the sample met DIPA criteria for a sleep insomnia, a prevalence that exceeds the 20–30 % of typically developing toddlers and preschoolers reported in the extant literature [34]. Problems with falling asleep, either as the only problem (23 %), or falling asleep
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Child Psychiatry Hum Dev Table 3 Sleep diary patterns and CBCL sleep problems in children with and without sleep disorders No sleep disorder N = 107
Sleep Onset Insomnia only N = 42
Sleep Onset ? Night Waking Insomnia N = 34
Bedtime Mean (SD) Range Asleep time
20:22 (0:44)
20:24 (0:51)
20:02 (1:02)
18:00–22:20
19:00–22:40
16:48–23:05
Mean (SD)
20:55 (0:55)
21:20 (1:09)
21:13 (1:20)
Range
18:27–23:29
19:33–24:33
18:30–24:54
F (2, 172) = 1.98, p = .14
F (2, 172) = 2.70, p = .07
Sleep onset latency Mean (SD)
0:33 (0:32)
0:57 (0:49)
1:13 (0:40)
Range
0:00–2:33
0:00–2:54
0:00–2:56
F (2, 172) = 13.76, p \ .001
Number WASOs Mean (SD)
0.5 (0.68)
0.8 (0.72)
1.3 (0.81)
Range
0.00–3.00
0.00–2.60
0.00–3.50
Mean (SD)
0:03 (0:03)
0:13 (0:13)
0:31 (0:31)
Range
0:00–0:35
0:00–1:54
0:00–3:20
F (2, 171) = 13.63, p \ .001
Duration WASOs F (2, 171) = 19.74, p \ .001
Wake-up time Mean (SD) Range Total sleep time
06:50 (0:35)
06:56 (0:41)
06:38 (0:40)
4:37–8:30
5:24–8:16
4:54–7:52
Mean (SD)
9:49 (0:51)
9:22 (1:03)
8:54 (1:28)
Range
7:28–11:51
6:08–11:05
5:12–11:14
F (2, 171) = 1.87, p = .16
F (2, 170) = 9.76, p \ .001
Sleep efficiency Mean (SD)
93.7 (5.61)
89.0 (9.23)
83.1 (10.20)
Range
71.3–100.4
64.3–100.2
56.1–100.0
F (2, 170) = 23.1, p \ .001
CBCL sleep problems Mean (SD)
59.0 (9.46)
69.8 (12.30)
79.9 (12.34)
Range
50–100
50–100
59–100
F (2, 157) = 44.0, p \ .001
WASO Waking after sleep onset, CBCL child behavior checklist
problems mixed with subsequent nighttime awakenings (14 %) were the predominant behavioral insomnias of childhood. It is interesting to speculate that the paucity of night waking only problems (4 %) reported for these children might reflect a general disorganization in these households where night waking might not be accompanied by signaling or signaling might not be heard by exhausted parents. As such, our estimated rates of NWI may be conservative, given our reliance on parental report for the assessment of nighttime arousals. Actigraphy studies could provide additional information about unreported night waking. We also examined diagnosed sleep disorders as related to parent-reported sleep-wake patterns (as assessed using daily sleep diaries over five nights) and general sleep concerns (as assessed using the Sleep Problems scale of the CBCL). Indeed, daily sleep diaries were significantly related to DIPA diagnoses of SOI and
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mixed sleep onset and Night Waking Insomnia (SOI ? NWI). Children who did not meet criteria for a DIPA sleep insomnia slept significantly more efficiently with shorter sleep onset latency times, shorter middle of the night awakenings, and longer total sleep time. The SOI and SOI ? NWI groups were further distinguished in that the SOI ? NWI group demonstrated the least efficient sleep and the lengthiest night awakenings, as well as the highest scores on the CBCL sleep concerns scale (see Fig. 2a–f). Such sleep deprivation is of significant clinical concern, given the associations between sleep disruption and behavioral disturbance, cognitive impairment, and deficits in attentiveness. Interestingly, evening bedtimes and morning wake-up times were not different for the sleep disordered and non-sleep disordered groups, suggesting that the different sleep patterns observed in these groups were not merely due to differences in family schedules and daily routines. It is also
Child Psychiatry Hum Dev Fig. 2 Sleep diary patterns in children, with no sleep disorder, Sleep Onset Insomnia (SOI), and Sleep Disorder ? Night Waking Insomnia (SOI ? NWI). a Differences in mean sleep onset latency (minutes) between groups. Different letters denote that groups are significantly different, p \ .05. b Differences in mean number of wakening after sleep onset (WASO) between groups. Note. Different letters denote that groups are significantly different, p \ .05. c Differences in mean duration (minutes) of wakening after sleep onset (WASO) between groups. Different letters denote that groups are significantly different, p \ .05. d Differences in mean total sleep time (minutes) between groups. Different letters denote that groups are significantly different, p \ .05. e Differences in mean sleep efficiency between groups. Different letters denote that groups are significantly different, p \ .05. f Differences in mean CBCL sleep problems between groups. Different letters denote that groups are significantly different, p \ .05
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possible that similarities in morning wake times were related to the pre-determined rise times required for participation in the day treatment program. Taken together, these study results contribute to the literature on early childhood sleep problems in several ways. Most importantly, we are aware of no previous study examining diagnostically defined sleep disorders in a clinical sample of preschool-aged children. The young children who participated in this study demonstrated a wide range of psychiatric problems, among which sleep disorders were common. Moreover, sleep problems typically cooccurred with other psychiatric diagnoses and were also associated with increased parent-reported behavioral concerns, both sleep and non-sleep related. Such findings suggest that, for some young children, sleep problems may
SOI + NWI
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be part of a diagnostically complex clinical picture characterized by a range of difficulties with emotional, behavioral and physiological self-regulation. Moreover, it is likely that these early childhood sleep and other behavioral problems are mutually intensifying, with disrupted sleep associated with increased emotional and behavioral dysregulation and with psychiatric symptoms (such as anxiety and agitation) associated with difficulties initiating and maintaining sleep. It is also likely that there are other, shared risk factors (e.g., family disorganization or stress) that contribute to both disrupted sleep and behavior problems in these clinically referred young children. Study findings also point to the need to assess and treat early childhood sleep problems, even when such problems are not the primary presenting clinical concern. In addition
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to the likely possibility that poor sleep serves to exacerbate co-occurring behavioral problems in young children, it may also be the case that sleep problems negatively impact the effectiveness of treatments to address primary behavioral concerns. For example, sleep-deprived children (and parents) may be too exhausted to benefit from interventions aimed to promote behavioral and emotional self-regulation. Further, in our own clinical experience, we have found that improvements in child sleep are frequently associated with improved daytime behavioral functioning, as well as providing families with renewed energy and positive momentum to tackle other behavioral concerns and clinical problems. In addition, although the nomenclature for diagnosing sleep disorders in young children remains controversial, findings of the present study suggest that SOI and NWI (and mixed SOI ? NWI) are useful descriptions for behavioral sleep problems as evidenced by very young children. Difficulties initiating and sustaining sleep may be distinct, but related facets of early sleep dysregulation, with some children demonstrating primary difficulties settling at bedtime (SOI) and other children demonstrating more recurring episodes of arousal and awakening at both bedtime and throughout the night (SOI ? NWI). Future research will be needed to determine whether difficulties with night waking (either alone or in combination with sleep onset problems) represent a qualitatively different aspect of sleep disturbance, or rather whether the mixed SOI ? NWI group may simply represent children with the most pervasive and impairing sleep problems.2 Future research will also be needed to examine the links between early childhood insomnias and pediatric sleep concerns not assessed in the DIPA, such as obstructive sleep apnea and night terror and sleepwalking parasomnias. Finally, this study is the first to report on the criterion validity of DIPA sleep disorders module, with findings demonstrating that DIPA-derived sleep disorder diagnoses related—in expectable ways—to data obtained using daily sleep diaries and the sleep problems scale of the CBCL. Moreover, the DIPA sleep disorders module may offer several important clinical advantages over these and other available sleep assessment tools, many of which are costly, time-consuming, and challenging to incorporate into routine practice. Studies comparing clinical data collected using the DIPA with that collected using both paper instruments and device-based measurements (particularly with respect to night waking episodes) will be an important next step in determining when and how the DIPA sleep module might be put to best clinical use, either alone or in
combination with other sleep assessment tools. Future research will also be needed to more fully evaluate the psychometric properties of the DIPA sleep disorders module, including more rigorous assessment of both interrater and test–retest reliability. While findings of the present study offer an important insight into the nature and diagnostic assessment of sleep problems in psychiatrically impaired preschoolers, several study limitations are of note. Although this is a carefully diagnosed group of seriously disordered preschool age children attending a partial hospital treatment program, the absence of a typically developing, age-matched control group, precludes certainty that our findings are specific to this population. However, our results are consistent with studies conducted with older children and adolescents that suggest that developmentally and behaviorally disordered youth are at increased risk for sleep problems. In addition, our study design did not include tracking of children’s naps. As some of the younger children were able to nap during the day in the program, total daily sleep may have been underestimated for these children. As well, given that children were assessed shortly after program admission, we did not focus on the impact of specific clinical interventions on children’s sleep (e.g., recommended changes in sleep hygiene). Relatedly, as psychopharmacology was not controlled, we cannot know the extent to which drug effects (both sedating and arousing) might have influenced children’s sleep. Finally, the early childhood day program from which our sample was drawn represents a highly specialized and possibly unique treatment setting and the extent to which findings might be generalized to young children treated in other, more typical or less intensive mental health settings is not known. In addition, future longitudinal research will be important in examining questions of temporal causality, including changes in sleep and behavior during treatment. For example, do sleep problems improve before behavior change, or conversely, does behavior change lead to better sleep? How can interventions for sleep disorders be best incorporated into the treatment regimens of seriously behaviorally disordered children? With notable exceptions [35], few studies have examined the impact of sleepfocused interventions for young children with acute psychiatric disorders, and we are aware of no studies that have done so with children and families experiencing such heightened levels of stress and psychopathology as in the present clinical sample.
Summary 2
We appreciated the comments of an anonymous reviewer who suggested ideas about a continuum of severity and shared arousal processes.
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Sleep problems are a significant clinical concern for many young children and their families. Although most research
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in this area has focused on samples drawn from the community and general pediatric practices, children with emotional and behavioral problems may be at particular risk. This study focused on the nature and prevalence of diagnostically defined sleep disorders, including SOI and NWI in a sample of 183 preschoolers (M age = 50.4 months) participating in a psychiatric day treatment program for young children with emotional and behavioral disorders. The Diagnostic Infant and Preschool Assessment (DIPA) was used to assess for SOI and NWI, using RDC. Findings suggested that sleep disorders were quite common in this acute clinical sample, with 41 % of participating children meeting criteria for a DIPA-defined sleep disorder and with sleep onset difficulties (either with or without night waking) being the most common sleep problem described. Parent-reported sleep concerns and diary sleep patterns of children who met criteria for a DIPA sleep disorder demonstrated significant differences from the patterns of children who did not meet DIPA criteria, with sleep-disordered children demonstrating longer latency to sleep onset, longer and more frequent night awakenings, less total sleep time, and lower sleep efficiency. Findings underscore the importance of assessing and treating disordered sleep in young children presenting with co-occurring psychiatric diagnoses and diverse behavioral impairments. Acknowledgments We are grateful to the children and parents who participated in this study. We also thank Mia DeMarco for her helpful assistance with this research project.
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