Clinical Assessment of Child and Adolescent Sleep Disturbance

This article provides guidelines for counselors interested in developing their own assessment procedure to evaluate child and adolescent sleep disturbance. The guidelines include reviewing the developmental and medical history, screening for parental psychopathology, obtaining a child behavior rating scale and sleep diary, and conducting a semistructured clinical interview to identify the sleep history and specific concerns. Considerations for referring clients for additional evaluation such as an overnight sleep study are discussed.     

Behavioral Sleep Problems in Children and Adolescents

Sleep problems in children and adolescents are common, and they impact multiple domains of child and family functioning. Psychologists have a critical role in the assessment and treatment of sleep problems and are integral to interdisciplinary sleep teams. Certain sleep problems may be related to co-morbid psychological or developmental conditions, and others are considered to be primarily medical, yet behavioral approaches may be applicable. There are also sleep problems considered to be behavioral in etiology (e.g. inadequate sleep hygiene, behavioral insomnia of childhood, nightmares/bad dreams/nighttime fears, delayed sleep phase syndrome, and psychophysiological insomnia). In this article, the assessment of behavioral sleep problems, as well as specific behavioral sleep disorders, and their treatments will be discussed.     

Mom,you're only remembering the bad behavior! the utility of distributed lag models in single-subject research

The present study examined if prior events/behaviors accounted for variance in parental perceptions of child behavior beyond that accounted for by those events/behaviors occurring simultaneously with the assessment of the parental perception. By utilizing a time-series analysis, this study investigated the relative effects of positive and negative child behaviors, interparental behavior, and intrapersonal behavior/events occurring simultaneously or at an earlier point in time on a mother's daily satisfaction with her clinic-referred child. Using a single-subject methodology with replication, nine mothers served as subjects. Data were collected across 30 days for participants, and subsequently, each mother's data were analyzed by multiple regression techniques. The results indicate the usefulness of distributed lag models for single-case designs in the absence of autocorrelation. Analyses indicate that for some mothers what happens on prior days with her child is as important or more important in determining her satisfaction with the child than what happens on the current day. In particular, mothers tend to carry over previous days' negative child behaviors into the present day's satisfaction rating. Previous days' positive and negative spouse behaviors and daily activities did not consistently contribute to regression equations predicting mothers' daily satisfaction ratings with their children.This research was supported in part by the University of Georgia's Institute for Behavioral Research.Data for this study were collected as part of a project designed to examine correlates of maternal satisfaction with their children. The primary results of the project have been reported by Furey and Forehand (in press). While the method in this study is basically similar to the Furey and Forehand (in press) method, the questions posed in the two studies differed.     

Sleep disorders in the first 18 months of life: Hypothesis on the role of mother-child emotional exchanges

Sleep disturbances of infancy (troubles in falling asleep, in the duration of sleep, night waking) are now the subject of renewed interest. Recently, these sleep problems in babies and young children seem to have increased in frequency and severity. A pilot study of sleep disorders is underway at the child department of the Hopital de la Poterne des Peupliers and involves more than 80 children aged 0–18 months. Twenty-nine infants have been selected from this cohort with severe and persistent sleep disorders that began in the first 18 months of life. In the absence of a control group, all cases were selected carefully. Some of the characteristics of these children are discussed: Age, sex, associated troubles, modalities of soothing, effect of hypnotic drugs, development under treatment. Some of these children are noted to be very active. Quite often, the pregnancy was marked by a traumatic event or by depression or anxiety in the mother. During evaluation of the mother-child interaction, one often notes a withdrawal of the mother's cathexis toward her child, which can go along with hyperstimulation in the relationship. This withdrawal concerns the emotional and fantasied dimensions of the interaction. The child's reactions and initiatives can be paralleled with the mother's speech, motor, and emotional attitudes. Thus, sleep disorders in early childhood represent an opportunity to observe the modalities of emotional exchange between mother and child and a methodologically interesting situation for the assessment of mother-child relationships.     

Child Sleep Problems and Parental Depression: Testing a Risk and Resistance Model

Although extensive studies demonstrate a link between infant sleep problems and parental depression, limited research explores this relation in parents of primary school aged children. Using cross-sectional data, we investigated direct, moderating and mediating risk and resistance factors in the relation between child sleep problems and parental depressive symptomatology in a sample of 145 Australian parents of primary school aged children. Parents completed the children’s sleep habits questionnaire, the short temperament scale for children, the perceived stress scale and the depression sub-scale of the depression, anxiety and stress–short form. Correlational analyses confirmed bivariate relations between parental stress and parental depressive symptomatology, and between child sleep problems and parental depressive symptomatology. Multiple regression analyses identified parental stress as a mediator of the relation between child sleep problems and parental depressive symptomatology, and the approach component of child temperament as a moderator of the relation between child sleep problems and parental depressive symptomatology. Findings suggest that parents of children with sleep problems experience increased stress levels and increased levels of depressive symptomatology and may be at increased risk of depression if their child has a difficult temperament characterized by low approachability. Implications for clinical intervention and future research are discussed.     

The Relationship Between Parent and Child Dysfunctional Beliefs About Sleep and Child Sleep

Cognitive theories emphasise the role of dysfunctional beliefs about sleep in the development and maintenance of sleep-related problems (SRPs). The present research examines how parents’ dysfunctional beliefs about children’s sleep and child dysfunctional beliefs about sleep are related to each other and to children’s subjective and objective sleep. Participants were 45 children aged 11–12 years and their parents. Self-report measures of dysfunctional beliefs about sleep and child sleep were completed by children, mothers and fathers. Objective measures of child sleep were taken using actigraphy. The results showed that child dysfunctional beliefs about sleep were correlated with father (r = 0.43, p < 0.05) and mother (r = 0.43, p < 0.05) reported child SRPs, and with Sleep Onset Latency (r = 0.34, p < 0.05). Maternal dysfunctional beliefs about child sleep were related to child SRPs as reported by mothers (r = 0.44, p < 0.05), and to child dysfunctional beliefs about sleep (r = 0.37, p < 0.05). Some initial evidence was found for a mediation pathway in which child dyfunctional beliefs mediate the relationship between parent dysfunctional beliefs and child sleep. The results support the cognitive model of SRPs and contribute to the literature by providing the first evidence of familial aggregation of dysfunctional beliefs about sleep.     

Why did adolescents have sleep problems after earthquakes? Understanding the role of traumatic exposure,fear, and PTSD

To examine the relationships between trauma exposure, fear, post‐traumatic stress disorder, and sleep problems in adolescents, 746 adolescent survivors of the 2008 Wenchuan earthquake in China were assessed at 1 year (T1) and 1.5 years (T2) after the earthquake using a trauma exposure questionnaire, a fear questionnaire, a child posttraumatic stress disorder symptom scale, and a subscale on child sleep problems. The results showed that T1 trauma exposure were not directly associated with sleep problems at T1 and T2, but played a positive role in sleep problems at both T1 and T2 indirectly through T1 posttraumatic stress disorder and T1 fear. T1 trauma exposure was also positively and indirectly associated with T2 sleep problems through T1 posttraumatic stress disorder via T1 sleep problems, or through T1 fear via the path from T1 posttraumatic stress disorder to T1 sleep problems. These findings indicated that fear and posttraumatic stress disorder 1 year after the earthquake played a mediating role in the relationship between trauma exposure at 1 year after the earthquake, and sleep problems at both 1 year and 1.5 years after the earthquake, respectively. In particular, posttraumatic stress disorder also had a multiple mediating effect in the path from trauma exposure to sleep problems via fear. Furthermore, the findings indicated that sleep problems were relatively stable between 1 and 1.5 years after an earthquake.     

Culture and the organization of infant sleep: A study in the Netherlands and the U.S.A.

This study investigates differences in the amount and structure of infant sleep in two cultural places with previously documented, divergent parental beliefs and practices. Eight-month-old infants (n = 24 per site) were recruited from towns in the Netherlands and the eastern U.S.A. To evaluate sleep, infants’ physical activity was recorded at home for 24 h using a miniature actigraph, while parents kept a diary of infant activities. Measures derived from actigraphy include total sleep, longest sleep episode, longest wake episode, number of sleep episodes, and percent of sleep during nighttime, as well as time in the stages of Quiet and Active Sleep. Measures based on the parental diaries include most of these aspects as well, except those related to sleep stages. Results based on the more precise actigraphy method indicate that (1) the Dutch infants averaged 13.65 h of sleep per 24 h, 1.67 h more than the U.S. infants; this difference was mostly due to daytime sleep; (2) The Dutch infants’ longest wake episode averaged less than that of the U.S. infants, while their longest sleep episode appeared slightly longer. (3) The Dutch infants, compared to the U.S. sample, spent more time in the Quiet, rather than the Active phase of sleep; (4) They began their Quiet sleep earlier in the evening than did their U.S. counterparts. Measures derived from parental diaries are largely in agreement with the actigraph findings. These results are consistent with reported and observed practices and beliefs in the two communities. The pattern of differences – less apparent maturity among the Dutch in the amount of sleep, but greater apparent maturity in the structure of sleep -- illustrates that behavioral and neurological maturity can be assessed only in the context of the developing child’s adaptation to the specific demands and affordances of the culturally structured developmental niche.     

Learning to sleep through the night: Solution or strain for mothers and young children?

Is the process of helping infants and young children learn to sleep through the night a solution to family sleep problems or does it exacerbate matters for mother and child? Retrospective and current accounts from a nonclinical, convenience sample of 102 mothers of preschool‐aged children provided information on sleep issues from early infancy through preschool age. Child, mother, and parenting characteristics, along with family sleep arrangements, were differentially related to the age at which children learned to sleep through the night and to the extent of difficulty that characterized this experience. Mothers who indicated more difficulty as their children learned to sleep through the night also reported more depressive symptoms and more strain in the mother–child relationship. Later age at sleeping through the night was more common among early bedsharers, but timing of sleeping through the night was not associated with preschool children's reported independence in several nonsleep domains. Sleep arrangements and the importance placed on sleeping through the night were the strongest contributors to variance explained in whether children learned to sleep through the night during infancy or toddlerhood. When advising parents about sleep interventions, practitioners should seek to understand whether families' parenting values fit their nighttime sleep practices.     

Response-restriction analysis: I. Assessment of activity preferences

We used procedures based on response-restriction (RR) analysis to assess vocational and leisure activity preferences for 3 adults with developmental disabilities. To increase the efficiency of the analysis relative to that reported in previous research, we used criteria that allowed activities to be restricted at the earliest point at which a preference could be determined. Results obtained across two consecutive RR assessments showed some variability in overall preference rankings but a high degree of consistency for highly ranked items. Finally, we compared results of the RR assessment with those of an extended free-operant assessment and found that the RR assessment yielded (a) more differentiated patterns of preference and (b) more complete information about engagement with all of the target activities.     

Children's assumptions about the generalizability of sex-typed abilities

Children (mean age = 103 months) were provided with information about the relative abilities of two stimulus children at a specific activity. They then were asked to predict which child would likely be superior at a second highly related activity. The two stimulus children were either same sex or opposite sex, and the activities in each pair were sex typed as male or female. The design was a 2 (sex of subject) × 2 (age of subject) × 4 (stimulus pair—MM, FF, MF, FM) × 2 (sex type of activities) mixed design, with sex of subject and age of subject as the between-subjects factors. Each child responded to 32 instances, representing four replications of eight possible combinations. The dependent variable was the child's choice of the initially superior child or initially inferior child as better at the second activity. The prediction was that children would be less likely to assume that superiority could generalize to a second activity if the initial superiority contradicted sexstereotyped expectations. This result would indicate that sex stereotypes interfere with inferences processes, supporting a scehmatic model of sex stereotyping. The results were consistent with the prediction. Compared to a baseline condition in which sex stereotypes were not relevant, children were less likely to choose the initially superior child when the sex stereotype had been violated, and more likely to select that child when it had been confirmed.     

Severity of sleep problems in children with severe learning difficulties: Description and correlates

In this study we have examined the percentage occurrence of settling and waking problems and of sleeping in the parents' bed in a sample of children with sleep problems. We found that about two-thirds had settling problems, nearly nine-tenths had waking problems, and one-third slept regularly in their parents' bed. Parents of children with sleep problems were more likely to experience a range of family problems than were parents of children without problems, and they were more likely to report a range of symptoms of stress. Most children with settling problems took at least two hours to settle to sleep at night. This behaviour was mainly tolerated or accepted by the parents. Parents gave a variety of suggestions as to triggers for settling problems, from being upset during the day to fears, illness and alterations in routine. Most parents thought the underlying explanation was the child's intellectual impairment. Over half the children with waking problems woke up every night, while 85% woke up at least three nights a week. One-third woke up three or more times a night. About two-thirds took up to half an hour to resettle, with one-third taking up to an hour. Parents (mainly mothers) tended to get up to attend to the waking child. About half of the children were thought to need attention because of physical disabilities. Illness, alteration in routine, becoming ‘overtired’ and ‘upset’ were thought to trigger waking problems. Intellectual impairment was again seen as the more general underlying reason for waking problems. Very few children were receiving treatment for their problems—7% were receiving medication and one was receiving a behavioural programme. Few parents had a systematic bedtime routine for their child and few had a consistent agreed response to settling or waking problems. When we examined the relationship between certain family variables and severity of sleep problems a number of relationships were found. Sleep problem severity was related to maternal responsiveness, maternal stress, impact of the child on the family, maternal behaviour towards the child, maternal attitudes towards the child and marital satisfaction. Severity of sleep problems was also related to certain child characteristics. Children with more severe problems tended to present more problems in their daytime behaviour. Sleep problem severity was also found to be related to child communication skills. These findings, together with those from other pilot studies, suggest that using behavioural methods of managing sleep problems might prove a promising way forward.     

USE OF NEGATIVE REINFORCEMENT IN THE TREATMENT OF SELF-INJURIOUS BEHAVIOR

Behavioral assessment procedures were used to determine the maintaining conditions of self-injury exhibited by 2 children with severe multiple handicaps. For both children, negative reinforcement (escape from grooming activities) was determined to be the maintaining reinforcer for self-injury (hand/arm biting) within an alternating treatments design. The treatment packages involved the use of negative reinforcement (brief escape from grooming activities) contingent upon a behavior that was incompatible with self-injury (reaching and pressing a microswitch that activated a prerecorded message of “stop”). Treatment was evaluated with a reversal design for 1 child and with a multiple baseline across grooming activities for the 2nd child. The treatment led to a marked decrease in self-injury for both children. At follow-up, high rates of self-injury were reported for the 1st child, but low rates of self-injury and an increase in task-related appropriate behavior were observed for the 2nd child.     

The effects of a responsive parenting intervention on parent-child interactions during shared book reading

This study examined mother-child shared book reading behaviors before and after participation in a random-assignment responsive parenting intervention called Play and Learning Strategies (PALS) that occurred during infancy (PALS I), the toddler-preschool (PALS II) period, or both as compared with a developmental assessment (DAS) intervention (DAS I and/or II). The efficacy of PALS was previously demonstrated for improving mother and child behaviors within play contexts, everyday activities, and standardized measures of child language. We hypothesized that PALS effects would generalize to influence maternal and child behaviors during a shared reading task even though this situation was not a specific focus of the intervention and that this would be similar for children who varied in biological risk. Participation in at least PALS II was expected to have a positive effect due to children's increased capacity to engage in book reading at this age. Four groups of randomized mothers and their children (PALS I-II, PALS I-DAS II, DAS I-PALS II, DAS I-II) were observed in shared reading interactions during the toddler-preschool period and coded for (a) mother's affective and cognitive-linguistic supports and (b) child's responses to maternal requests and initiations. Support was found for significant changes in observed maternal and child behaviors, and evidence of mediation was found for the intervention to affect children's behaviors through change in maternal responsiveness behaviors. These results add to other studies supporting the importance of targeting a broad range of responsive behaviors across theoretical frameworks in interventions to facilitate children's development.     

The Stability of Child Problem Behaviors: A Longitudinal Analysis of Inner-City African American Children

We focused on the stability of child problem behaviors in a sample of 124 low-income inner-city African American families. Internalizing and externalizing problems were assessed longitudinally across four years. Test-retest correlation coefficients indicated that the relative stability of both internalizing and externalizing problems over the four-year assessment was high for both child and mother reported variables. Partial support was obtained for absolute stability of child problem behavior as analyses of variance revealed that two of four variables of interest did not change significantly over time. Mother report of child problem behavior was more stable than child report, but gender of child or type of problem behavior (internalizing vs. externalizing) was not related to stability. Hierarchical multiple regression analyses revealed that the historical context of child problem behaviors is important to consider, as earlier problem behaviors accounted for unique variance in later problem behaviors, beyond that accounted for the most recent assessment.     

Longitudinal Relations Between Parent–Child Conflict and Children’s Adjustment: The Role of Children’s Sleep

Sleep was examined as a process variable in relations between verbal and physical parent–child conflict and change in children’s internalizing and externalizing symptoms over time. Participants were 282 children at T1 (M age?=?9.44 years; 48 % girls), 280 children at T2 (M age?=?10.41 years), and 275 children at T3 (M age?=?11.35 years). Children reported on parent–child conflict, sleep was assessed with actigraphy, and parents reported on children’s internalizing and externalizing symptoms. Autoregressive effects for sleep and internalizing and externalizing symptoms were controlled to examine change over time. Supportive of intervening processes, physical parent–child conflict at T1 and increased change in internalizing and externalizing symptoms at T3 were indirectly related through their shared association with reduced sleep continuity (efficiency, long wake episodes) at T2. Findings build on a small but growing literature and highlight the importance of considering the role of sleep in relations between family conflict and child development.     

An observational case study of failure in social problem-solving

An observationally based assessment of social problem-solving skill was contrasted with more traditional testing methods. A preschool child with low social success was chosen for a demonstration profile analysis. The relative frequencies of the social goals, strategies, and targets shown by this child during free play were plotted in relation to that of his same-sex peer group. Parallel profiles of his relative success with specific goals, strategies, and targets were also constructed and compared to relevant group means and standard deviations. Specific social problem-solving strengths and weaknesses were identified from these profiles, using both intra- and interindividual analyses. The benefits and limitations of this approach for measurement and treatment of social problem-solving deficits were discussed.     

Sleep arrangements and maternal adaptation in infancy

Among the many decisions that parents make regarding child‐rearing practices, an important one involves sleep arrangements. Little is known about the relationship between chosen sleep arrangements, parents' adaptation to these choices, parental sleep quality, spousal support, and parental distress. Forty‐five mothers and fathers with infants 1 to 24 months old completed measures of parental attitudes and practices regarding sleep arrangements. Shared sleep with one's infant was associated with poorer parental adaptation to infant sleep disruption, and this was true even when parents endorsed the practice of sharing sleep with their infants. Among mothers, shared sleep and poorer adaptation to infant sleep were significantly associated with elevated depressive symptoms, poorer sleep quality, and spousal criticism directed to mothers about where the infant slept during the night. For mothers, criticism from their spouses about where the baby slept, mothers' sleep quality, and depressive symptoms mediated the link between sleep arrangements and maternal adaptation. Results emphasize the importance of taking into account individual differences in the quality of parents' adaptation to infant sleep behavior, a construct largely ignored in the child sleep literature to date, in understanding linkages between infant sleep quality and infant–parent outcomes.     

Increased Jump Height with an External Focus Due to Enhanced Lower Extremity Joint Kinetics

Sensorimotor abilities are crucial for performance in athletic, military, and other occupational activities, and there is great interest in understanding learning in these skills. Here, behavioral performance was measured over three days as twenty-seven participants practiced multiple sessions on the Nike SPARQ Sensory Station (Nike, Inc., Beaverton, Oregon), a computerized visual and motor assessment battery. Wrist-worn actigraphy was recorded to monitor sleep–wake cycles. Significant learning was observed in tasks with high visuomotor control demands but not in tasks of visual sensitivity. Learning was primarily linear, with up to 60% improvement, but did not relate to sleep quality in this normal-sleeping population. These results demonstrate differences in the rate and capacity for learning across perceptual and motor domains, indicating potential targets for sensorimotor training interventions.     

Early childhood co-sleeping: Parent-child and parent-infant nighttime interactions

This study investigated parent—child interactions during sleep onset and nighttime arousals in a rural sample of preschool children. The role of co-sleeping in relation to sleep habits and night waking was examined using parental self-report of both current and retrospective sleep patterns. The results showed that Solitary Sleepers engaged in more complex bedtime routines, and had more longstanding and stronger attachment to security objects and sleep aids, than did Co-sleepers. Infancy precursors to co-sleeping in early childhood were a history of breastfeeding, night feedings in the parent's bed, and returning to sleep in the parent's bed.