Our intervention aimed to improve a BSP at an age when infants are developmentally capable of sustaining a long self-regulated sleep period for, on average, 10 h . We sought to change families’ cognitions and be- haviors to promote infant self-soothing and targeted our intervention to both parents because both have affected infant sleep . Parental cognitions are defined as be- liefs, expectations, and interpretations of children’s sleep behavior which are viewed as influencing parent-infant interactions and infant sleep patterns [22, 23]. Because public health nurses frequently encounter families ex- periencing infant BSP we trained them to deliver the sleep intervention. Nurses also delivered the safety con- trol sessions. The principal investigator created the ma- terials for the teaching sessions and phone calls. Total treatment duration was 3 weeks: one 2-h teaching ses- sion followed by bi-weekly telephone calls for 2 weeks. The nurses who delivered the teaching sessions called the parent leading the intervention/control twice a week for 2 weeks to reinforce concepts and provide support. The intervention and control groups were asked the same questions during the telephone calls: How were parents managing; what strategies were they using; what were the effects of their strategies on their infants and the parents; and what, if any, difficulties were they experiencing?
(anxiety, depression) and external (delinquent, aggressive) behavioral disturbance . Recent surveys report about correlations between sleep disturbance and behavioral disturbance. There are no reports about the causal direc- tion of correlation between sleep and behavioral distur- bance. Behavioral disturbance is supposed to get wors- ened by sleep disturbance and vice versa.  reported about children suffering habitual snoring, who are highly significantly more affected with hyperactivity and inat- tention than children without habitual snoring. One year later, children who were not suffering from habitual snoring anymore showed regressive behavioral disorder (hyperactivity and inattention). Children who persisted in suffering habitual snoring were still affected with behav- ioral disorder. Therefore treatment of sleep disorder can reduce behavioral disorder.
The current study was part of a Dutch study on the relation between sleep characteristics and learning ability of 9-11 year old children and was conducted in collaboration with the Dutch Sleep Registry. The sample was defined by non-clinical school-aged children (9-11 years old). Participants were mainly recruited from mainstream elementary schools in the Netherlands, but also from child daycares and social networks of the researchers. Of the 154 schools and child daycare centers approached, only 94 schools received the information letter. Consent for participation was received from 54% of the schools. After schools and child daycare facilities gave their consent, a total of 4409 parents were approached of whom 4323 parents received information about the study. Written informed consent was obtained from 653 parents (response rate 15%) of whom 47 withdrew before the start of the study. Not filling out instruments used to measure chronotype, behavior and sleep (n = 121), and not providing background information like gender and age (n = 2) were used as exclusion criteria. The sample consisted 483 children, of whom 219 boys and 264 girls. The mean age was 10.49 years (SD = 0.85, range 8.98-12.47). The majority (97.5%) of the participants had Dutch nationality. Most of the children (88.3%) were living with both parents. For 88.9 percent of the children the questionnaires were filled out by their mother. The majority of the respondents received a college level education (47.1%) or at least secondary education (35%).
As for ASD, the results revealed that sleepproblems were not related to eveningness and that there were no dif- ferences in eveningness scores between ASD and normal controls. Those results indicate that although ASD might be associated with disturbances in melatonin production and rhythm , those melatonin disturbances may not affect sleep wake rhythm. That is in accordance with a recent study showing that children with ASD and insomnia who were responsive to a low dose of melatonin had rela- tively normal profiles of baseline endogenous melatonin and normal pharmacokinetic melatonin profiles after sup- plemental melatonin administration . Thus, apparently, melatonin did not improve sleepproblems in ASD through replacing endogenous melatonin or acting on the circadian system. It remains unknown what the behavioral correlates of the endogenous melatonin disturbances in ASD are, but evidence suggests that sleepproblems in ASD are not asso- ciated with a delayed circadian system, but might be due to an inadequate sleep hygiene. Sleep hygiene interven- tion studies in the ASD population are scarce so far , however the current findings suggest that sleep hygiene improvement might be an effective intervention strategy in children with ASD. Nevertheless, the results showed that negative effects of inadequate sleep hygiene disappeared when the predictive model included anxiety and depres- sive problems. This contradicts the possible role of sleep hygiene, and emphasizes the importance for future studies to control for anxiety and depressive problems.
Residents’ responses provide implications for training. For instance, the need for a greater focus on knowledge-based training in the treatment of childhood psychological disorders as well as developmentally normative problems such as sleep and toileting (diagnosis vs. treatment, training issues). Relatedly, didactic and experiential training in psychotropic medication management is a significant need for residents, who generally receive little training prior to residency and typically only with adult populations (psychiatric medications). Training in this area is particularly important given that pediatricians often prescribe psychiatric medications for children due to the shortage of child psychiatrists in this country (Kelleher, Hohmann, & Larson, 1989; Mark, Levit, & Buck, 2009).
Children with SDB had twice the odds of having CBCL total problem scores in the borderline or clin- ical range compared with children without SDB, and these differences persisted after covariate adjustment (adjusted OR: 2.2; 95% CI: 1.4 –3.4; P ⫽ .001). Because the CBCL and CPRS-R:L identify many similar be- havioral constructs, the remaining behavioral out- comes were grouped into 2 broad problem catego- ries: externalizing, internalizing, and social problems and competencies. The unadjusted and adjusted re- lationships between SDB and these behavioral out- come groups are summarized in Tables 2, 3, and 4, respectively. Compared with children without SDB, children with SDB had 2.6 times the odds of having a borderline or clinically abnormal score for the CBCL externalizing scale (95% CI: 1.6 – 4.3; P ⬍ .001). Analyses of individual scales indicated that com- pared with children without SDB, children with SDB had significantly higher odds of the following acting- out behavior problems: hyperactivity (1.8; 95% CI: 1.2–2.8; P ⫽ .010), emotional lability (2.9; 95% CI: 1.7– 4.8; P ⬍ .001), oppositional (2.3; 95% CI: 1.4 –3.9; P ⫽ .010), aggressive (4.9; 95% CI: 2.4 –9.9; P ⬍ .001), and another index of hyperactivity, the CPRS-R:L Global Total Index (1.9; 95% CI: 1.1–3.1; P ⫽ .015). Although unadjusted analyses for attentional scales (CBCL attention, CPRS-R:L cognitive/inattention, and CPRS-R:L attention-deficit/hyperactivity disor- der) showed a significant association with SDB, these relationships were not statistically significant after controlling for confounders. SDB was not signifi- cantly associated with thought problems in either unadjusted or adjusted analyses.
The behavioral manifestations of daytime sleepi- ness in young children, such as hyperactivity, clearly overlap with problematic behaviors that do not re- sult from sleep deprivation/disruption. The results of a cross-sectional study, such as this one, do not allow us to draw direct conclusions about the nature of the relationship between sleep disturbance and daytime sleepiness-associated behavior. Alternative explanations for the finding of increased externaliz- ing behavior problems in the BSD groups include the possibility that children with oppositional or aggres- sive behavior during the day are also likely to man- ifest similar behavior at bedtime. Other factors, such as an overall negative parental perception of both their child’s bedtime and daytime behavior, may be operative. It would be important in future studies to correlate more objective sleepiness measures, such as the Multiple Sleep Latency Test, 39 and multiple ob-
In this study we aimed to evaluate the relation between eveningness, sleep variables, cognitive measures, and behavioralproblems. Recent studies found that children showing an eveningness preference display more behavioralproblems. However, to date it is still unknown which pathways are at the root of these relation. One of the hypotheses in this study was that sleep quantity and sleep quality might mediate the relation, since eveningness is associated with less sleep and increased sleep variability. Moreover, other studies have also indicated that cognitive functioning can be influenced by sleep quantity and/or quality. Therefore, several measures of cognitive functioning, especially attention, were also included as outcome measures here. This study is new in that it explores a variety of relations between these important areas and tries to provide insights into possible pathways by which these processes might take place. The results of the present study confirm the main hypothesis, i.e., that circadian preference (morningness- eveningness) partly predicts behavioralproblems. Children with a preference towards eveningness showed more internalizing and externalizing behavioralproblems than children showing a preference towards morningness, as reported by their parents. This is in line with recent study results that demonstrated that these children and adolescents are more often reported as showing behavioralproblems (Gianotti et al., 2002; Gau et al., 2007; Goldstein et al., 2007; Paavonen et al., 2009; Lange & Randler, 2011). However, previously reported associations of eveningness with ADHD-related symptoms of inattentiveness could not be replicated (Caci, Bouchez, & Baylé, 2009; Paavonen et al., 2009). In the relation between chronotype and cognitive functioning we found a significant positive association only with verbal cognitive reasoning was found. This contradicts the hypothesis that eveningness is associated with lower cognitive functioning. How this might be explained will be discussed below.
Parental mismanagement of sleep routines is a family factor due to sleepproblems in children (Jones, Pollard, Summerbell, & Ball, 2014). Parenting attitude also a factor that positively correlates to child sleepproblems (Jones et al., 2014; X. Liu, Liu, Owens, & Kaplan, 2005). Some non-pharmacological recommendations for parents include music therapy, counseling, sleep education programs, early care and education program, behavioral therapy and sleep hygiene (Gonzales, 2013; Gruber, Cassoff, & Knäuper, 2011; Halal & Nunes, 2014; Hockenberry & Wilson, 2014; Mindell, Kuhn, Lewin, Meltzer, & Sadeh, 2006; Staton et al., 2016; Wilson, Miller, Bonuck, Lumeng, & Chervin, 2014). Recommendations for parents to address sleepproblems in children can be provided by health workers including nurses (Gruber et al., 2011).
electrooculography (EOG), and finger pulse oximetry. EEG electrodes were placed bilaterally along the antero- posterior axes at locations F3, F4, C3, C4, P3, P4, O1, and O2. Sleep stages were scored visually on screen (LUNA; Stellate Systems, Montreal, Canada) using pri- marily central derivations (referential derivation to linked ears) according to standard AASM criteria . To assess breathing two respiratory belts measuring chest and abdominal movement were used to detect hypopnea and central apneas, and pulse oximetry was used to measure oxygen saturation. The decision not to use nasal cannulae was based on the desire to not inter- fere with the child’s sleep, which would have impact on ecological validity. A diminution of ≥50% in chest or ab- dominal belt signal was considered to reflect hypopnea, whereas a complete absence of respiratory effort signal was defined as central apnea. Subjects with a hypopnea/ central apnea index (AHI) >2 per hour of sleep were re- ferred for a complete assessment of sleep related breath- ing disorders. Note that clinical views on the AHI values that should be used to define SDB and potential SDB differ. Previous studies on the relationship between ADHD and sleep used AHI values of 2  to 5  whereas some authors suggest that an AHI >1 should trigger evaluation . We chose an AHI >2 for our work as it is consistent with the clinical practice of sev- eral leading Canadian sleep centers, and is at the low end of the thresholds set in previous works on the same topic. EMG leg electrodes were used to characterize leg movements during sleep. A periodic leg movement index greater than 5 per hour of sleep was considered to represent an elevated value, and these subjects were excluded from the study. Various PSG sleep measures were analyzed, but, in the present study the primary variable was sleep latency. In addition, sleep duration, the amount of time spent in each sleep stage, and sleep efficiency were calculated.
There are a number of findings on the effectiveness of be- havioral approaches in the treatment of childhood sleepproblems. For example, a randomized controlled clinical study by Mindell, Telofski, Wiegand, and Kurtz (2009) assessed the impact of establishing a sleep routine on ma- ternal sleep and mood in 405 seven-month-old children and their mothers. The results showed a decrease both in sleep onset latency and in night waking, thus indicating an improvement in infant sleep. An improvement in maternal mood was also observed. Another randomized clinical trial (Mindell et al., 2011a) with 264 mothers and their children aged 6 months to 3 years assessed the effectiveness of an internet-based intervention for childhood sleepproblems. In this study, there were three study conditions: a bedtime routine condition, a bedtime routine + behavioral internet-based condition (the Customized Sleep Profile), and a wait list control. The guidelines in this study involved the following: establishing routines and breaking inappro- priate associations with sleep onset. While in one of the groups, the establishment of routines was informed in a de- tailed manner for the caregivers, with specific guidelines such as bath, moisturizing massage lotion, and calm activ- ities such as a lullaby and reducing the light around 30 min at the end of the bath. The results showed that in both treatment groups, significant improvements were observed in sleep onset latency and the number/duration of night wakings. An increase in total sleep time was observed, in addition to the confidence of the mothers in the manage- ment of their children ’ s sleep. The improvements were ob- served in the first week, with additional benefits in the second week. There were also improvements in maternal variables, both in terms of sleep and in the mood as well.
apnea or enuresis, and the fact that sleepproblems are so strongly related to other psychological and medical problems. Inquiring about sleepproblems may provide valuable information about behavioral (noncompliance), emotional (fears, depression), or medical problems (asthma, medication) that are co- occurring with reports of sleepproblems. Inquiring about sleep may be an important keystone behavior that can provide insight into a variety of other be- haviors, including those related to psychiatric and medical functioning. The fact that so few of the par- ents who reported sleepproblems in their children discussed sleep with their pediatrician suggests that interviewing parents and children about sleep needs to be emphasized more during routine pediatric vis- its. Moreover, discussing sleep patterns provides an opportunity to learn more about the child and fam- ily, to evaluate environmental and family interaction, and to educate the parents about good sleep hygiene with the hope of preventing more serious or chronic sleep-related problems.
each child's caregiver (mostly the mothers) at baseline, which was the day of enrolment for the CC children or a week after discharge for children with CM and SMA. Subsequent study visits were done at 6, 12, and 24 months after baseline testing for CC children or after discharge for CM and SMA children. Children were scored on the syndrome scales, which are: emotionally reactive, anxious/ depressed, somatic complaints, withdrawn, attention problems, aggressive behavior, and sleepproblems. These were summarized into internalizing problems (emotionally reactive, anxious/ depressed, somatic complaints, withdrawn), externalizing problems (attention problems, aggressive behavior) and total problems, which included both internalizing and externalizing problems as well as 2 more scales, sleepproblems and other problems. 15
Sleep needs change over time, and total sleep time needed tends to decline as the individual ages. According to the National Heart, Lung, and Blood Institute, newborns require 16 - 18 hours per day, preschool aged children require 11 - 12 hours per day, school aged children require at least 10 hours per day, and ado- lescents require 9 - 10 hours per day (National Heart, Lung, and Blood Institute, 2017). However, many children do not receive adequate sleep due to various sleep disturbances, leading to daytime sleepiness as well as a multitude of other negative outcomes (Fallone, Owens, & Deane, 2002). The negative consequences of sleepproblems in children and adolescents have been well documented and include mood disturbances, anxiety, behavior problems, neurocognitive deficits, hyperactivity, and academic and learning struggles (Fallone et al., 2002; Mindell et al., 2006; Owens, 2008). Additionally, research has found that delayed sleep onset in adolescents and early school start times are associated with a variety of negative consequences including reduced academic performance, anxiety, de- pression, social skills deficits, behavioral disturbances, and mood disturbances (Owens, 2008; Wolfson & Carskadon, 1998). Research has begun to specify cha- racteristics of the relationship between sleep disturbances and behavior prob- lems in children (Aronen, Paavonen, Fjallberg, Soininen, & Torronen, 2000; Owens, 2008). Specifically, children with sleep disturbances are more likely to struggle with aggression, conduct problems, inattention, and hyperactivity (Chervin, Dillon, Hedger Archbold, & Ruzicka, 2003; Chervin et al., 2002). This is of particular relevance to mental health care providers, as behavior problems and disruptive behavior disorders are some of the most common reasons for re- ferrals in pediatric mental health clinics (Verhulst & Van Der Ende, 1997; Wu et al., 1999).
Emotional, behavioral, and relationship problems can develop in very young children, especially those living in high-risk families or communities. These early problems interfere with the normative activities of young children and their families and predict long-lasting problems across multiple domains. A growing evidence base demonstrates the efﬁ cacy of speciﬁ c family- focused therapies in reducing the symptoms of emotional, behavioral, and relationship symptoms, with effects lasting years after the therapy has ended. Pediatricians are usually the primary health care providers for children with emotional or behavioral difﬁ culties, and awareness of emerging research about evidence-based treatments will enhance this care. In most communities, access to these interventions is insufﬁ cient. Pediatricians can improve the care of young children with emotional, behavioral, and relationship problems by calling for the following: increased access to care; increased research identifying alternative approaches, including primary care delivery of treatments; adequate payment for pediatric providers who serve these young children; and improved education for pediatric providers about the principles of evidence-based interventions.
There were signi ﬁ cant differences among the clusters for 16 of the 17 putative covariates (Table 2). Children in the symptomatic clusters had the most adverse risk pro ﬁ le, led by those in the “ Worst ” cluster, and followed by those in the “ Late Symptoms ” cluster. In contrast to SEN associations with sam- ple characteristics, the normals were signi ﬁ cantly less likely to be premature or low birth weight or to have had mothers who reported smoking or drinking alcohol in pregnancy. There was a 4-point IQ difference between the “ Worst ” (mean 102.4, SD 16.3) and nor- mal (mean 106.4, SD 16.1) clusters.
The findings of the present research have some implications regarding the importance of extending the duration of physical education courses in schools and kindergartens. SPARK can act as a supplemental treatment for children with ADHD. It may be useful in controlling symptoms like restlessness, anxiety, and excessive activity. Therefore, it is recommended to enrich physical education programs by making use of SPARK activities in special education schools. This may help improve the attention and behavior of children with ADHD, which in turn results in better academic performance. In this regard, school administrators are encouraged to provide health-related physical education programs, because these activities may confer physical, mental, and behavioral health benefits on students. Considering the results of the study, it is also recommended to psychiatrists, counsellors, and psychotherapists to put the SPARK physical education program into focus in clinical settings. The presented conclusion in the paper may have some limitations. According to the sampling strategy, generalization of the findings to other samples should be done carefully.
For the control group, the following inclusion criteria were used as follows: 1) no psychiatric disorder diagnosis according to DSM-5 (not meeting the diagnostic criteria of any psychiatric disorder according to DSM-5); 2) an age range of 2–18 years; 3) not having a chronic physical or mental illness; 4) not using any medications for at least 6 months; 5) for preschoolers, normal developmental history and normal Denver II Test; and 6) for school-aged children, normal intelligence based on either a Wechsler Intelligence Scale for Children-Revised (WISC-R) 10 full-scale IQ score
Eating disorders primarily affect adolescent girls and young adult females and are considered to be rare among males. These include AN, binge eating (BE) (also known as compulsive overeating), bulimia nervosa (BN), and sleep- related eating disorder (SRED). AN is characterized by self- starvation and excessive weight loss, including psychiatric symptoms such as intense fear of weight gain or being “fat” and feeling “fat” or overweight despite dramatic weight loss, and is behaviorally expressed by sore throat and pain- less swelling of the cheeks from vomiting. BE is primarily characterized by periods of uncontrolled, impulsive, or con- tinuous eating beyond the point of feeling comfortably full. Behaviorally, it is characterized by eating large amounts of food when not physically hungry, rapid eating, feelings of disgust, depression, or guilt with overeating. Patients with BE usually do not purge afterward by vomiting or using laxatives. Diagnosis of BN is more difficult than AN and BN; girls with BN try to remain at normal body weight or above while binge eating and purging. 204 Patients with SRED gener-